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A01 LOCAL INFILTRATION ANALGESIA IN TOTAL HIP ARTHROPLASTY: A PHARMACOKINETIC STUDY OF KETOROLAC F. Affas, S. Eksborg, P. Wretenberg, N. Stephanson, C. Olofsson, C.-O. Stiller 1 2 3 4 Anesthesia and Intensive Care, Department of Women and Child Health, Orthopedics, Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden Introduction: Local Infiltration Analgesia (LIA) is widely used in the last decade as a method of postoperative treatment after lower extremity arthroplasty. In the LIA technique a mixture of a longacting local anaesthetic (ropivacaine), a non-steroidal anti-inflammatory drug (Ketorolac), and epinephrine are infiltrated intra operatively in all traumatized tissue. This method has certain advantages, which include administration at the site of traumatized tissue, minimal systemic side effects, faster postoperative mobilization, earlier postoperative discharge from hospital and less opioid consumption. However, information regarding plasma concentrations of ketorolac after LIA mixture is insufficient to predict the risk of renal impairment in patients subjected to arthroplasty. The aim of this study is to determine the maximal plasma concentration and the exposure of ketorolac during the first 30 h following infiltration in hip arthroplasty. Methods: In a prospective open trial thirteen patients scheduled for primary total hip arthroplasty received LIA (ropivacaine 200 mg, ketorolac 30 mg and epinephrine 0.5 mg) in a volume of 106 ml. Plasma concentration of ketorolac was quantified by liquid chromatography- mass spectrometry (LCMS). Results: The range of the maximal plasma concentration 0.3 - 2.2 mg/L, was detected 30min - 4 hours after completing the infiltration. Discussion: In contrast to a common belief, the plasma concentration of ketorolac after LIA is not negligible, but within the same range as after intramuscular injection of the same dose of ketorolac to healthy elderly volunteers. Caution should be taken when having ketorolac in LIA as a method in treating post-operative pain in hip arthroplasty, with specific attention to risk factors that predispose a patient to renal dysfunction. References: 1. Aitken, H. A., J. W. Burns, C. S. McArdle and G. N. Kenny (1992). "Effects of ketorolac trometamol on renal function." Br J Anaesth 68(5): 481-485.2. 2. Brocks, D. R. and F. Jamali (1992). "Clinical pharmacokinetics of ketorolac tromethamine." Clin Pharmacokinet 23(6): 415-427.3. 3.Jallad, N. S., D. C. Garg, J. J. Martinez, E. J. Mroszczak and D. J. Weidler (1990). "Pharmacokinetics of single-dose oral and intramuscular ketorolac tromethamine in the young and elderly." J Clin Pharmacol 30(1): 76-81. Nothing to disclose This study was approved by the Regional Research Ethics Committee at the Karolinska Institutet in Stockholm and by the Swedish Medical Products Agency. A02 PERSISTENT PAIN AFTER TOTAL KNEE ARTHROPLASTY (TKA): INCIDENCE, CHARACTERISTICS AND PREDICTIVE FACTORS 1 2 2 I. Grosu , E. Thienpont , M.-N. France , P. Lavand'homme 1 2 2 Anesthesiology, Cliniques Universitaires Saint Luc, Bruxelles, Cliniques Universitaires Saint Luc, Brussel, Belgium Background and goals: Chronic pain after surgery (CPSP) may concern a large number of patients, the major cause being related to surgical nerve trauma (1). Psychological factors play a major role in the development of CPSP including after a nerve injury. The present study is aimed to identify risk factors and characteristics of CPSP after TKA, a common surgical procedure. Methods: After IRB approval and informed consent, patients undergoing primary TKA filled in preoperatively anxiety (HAD) and catastrophization (RCD) questionnaires. A single surgeon performed all surgeries under standardized anesthesia protocole. All patients received multimodal analgesia including single dose 300 mg pregabalin preoperatively. Postoperative pain scores were recorded from day1to day8 (VAS 0-10) at rest and movement. Patients answered Brief Pain Inventory (BPI) and neuropathic pain DN4 questionnaires by phone call at 3 months. Statistical analysis used unpaired t-tests and Pearson's correlation, p< 0.05 was significant. Results: 62 patients were included; 52 patients (84%) answered the 3 months questionnaire. 62% had CPSP, 11% presented neuropathic pain features. Average CPSP score was 2 (0-7) and worse pain 4 (2-9). Neuropathic pain was associated with higher intensity of CPSP. 40% CPSP patients were taking analgesics with an average pain relief of 60% (20-100%). CPSP and pain free patients at 3 months did not differ for age, gender, BMI, preoperative pain score. However, CPSP patients presented with significantly higher acute pain scores at mobilisation than pain free patients from day2 to day6. Preoperative catastrophization and anxiety scores did not correlate with CPSP at 3 months but there was a positive correlation between intensity of acute pain at movement on day3 and day4 and the development of CPSP, specifically neuropathic pain (r = 0.440;p< 0.01). Discussion-conclusion: Our results are in agreement with the literature showing that CPSP is frequent after TKA but from low neuropathic origin (2). Acute pain severity during mobilization, specifically at day3 and day4, may be an interesting predictor of CPSP neuropathic pain after TKA. The lack of catastrophisation and anxiety scores predictive value might be due to preoperative pregabalin administration in all patients, an intervention that deserves further studies. (1) Kehlet et al, Lancet 2006; (2) Haroutiunian et al, Pain 2013. A03 EFFECTS OF INTRATHECAL INJECTION OF CAMKⅡ INHIBITOR KN93 ON REMIFENTANILINDUCED HYPERALGESIA IN RATS X. Gu, Z. Ma, C. Cheng, J. Zhang, W. Zhang Department of Anaesthesiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China Introduction: Our previous studies have shown that tyrosine phosphorylation of the NR2B at Tyr1472 1 in spinal dosal horn contributes to postoperative hyperalgesia induced by remifentanil . 2+ Calcium/calmodulin-dependent protein kinase Ⅱ (CaMKⅡ) can be activated by Ca influx through 2 NMDA receptors . This study aimed to investigate the effects of intrathecal injection of CaMKⅡ inhibitor KN93 on the hyperalgesia induced by remifentanil in a rat model of incisional pain. Material and methods: All experiments were approved by the Animal Care and Use Committee at the Medical School of Nanjing University. 75 SD rats were divided randomly into 5 groups (n=15): group R (rats underwent a surgical incision and remifentanil 0.04mg/kg was infused subcutaneously at the moment of surgical incision over a period of 30 min), group I (rats underwent a surgical incision and subcutaneous infusion of the same volume of saline), group C (rats underwent a sham procedure without an incision), group DMSO (intrathecal injection of 10% DMSO 20µl 30 min before plantar incision and remifentanil infusion) and group KN93 (intrathecal injection of KN93 (50µg/20µl, dissolved in 10%DMSO) 30 min before plantar incision and remifentanil infusion). The paw withdrawal mechanical threshold (PWMT) and the paw withdrawal thermal latency (PWTL) were tested at 24 h before and 2h, 6h, 24h, 48 h after surgery. Results: Compared with that of group C, PWTL ((11.24±0.69)s, (10.36±0.29)s, (11.29±1.12)s, (12.21±0.75)s) and PWMT ((25.5±1.20)g, (24.92±1.98)g, (25.47±1.54)g, (27.14±1.04)g) of group I were significantly decreased at 2h, 6h, 24h, 48 h after surgery (P< 0.05). Compared with that of group I, PWTL ((8.48±0.72)s, (8.58±0.45)s, (8.46±0.92)s, (9.07±0.79)s) and PWMT ((21.2±2.42)g, (19.58±1.12)g, (21.87±1.56)g, (22.26±1.64)g) of group R were significantly decreased after surgery (P< 0.05). Compared with that of group R, PWTL ((13.32±0.73)s, (11.79±0.32)s, (11.86±0.98)s, (12.76±0.82)s) and PWMT ((29.75±1.38)g, (28.27±1.16)g, (26.5±1.02)g, (27.79±1.22)g) of group KN93 were significantly increased at the corresponding time points (P< 0.05). In addition, there was no significant difference in PWTL and PWMT between group DMSO and group R. Discussion: Intrathecal injection of CaMKⅡ inhibitor KN93 could relieve the postoperative hyperalgesia induced by remifentanil in rats. References: 1. Gu X, Wu X, Liu Y, Cui S, Ma Z. Tyrosine phosphorylation of the N-Methyl-D-Aspartate receptor 2B subunit in spinal cord contributes to remifentanil-induced postoperative hyperalgesia: the preventive effect of ketamine. Molecular Pain. 2009;5:76. 2. Katano T, Nakazawa T, Nakatsuka T, Watanabe M, Yamamoto T, Ito S. Involvement of spinal phosphoryLation cascade of Tyr1472-NR2B, Thr286-CaMKⅡ, and Ser83l-GluRl in neuropathic pain. Neuropharmacology. 2011;60(4):609-16. Funding: This research was supported by National Natural Science foundation of China Grant no. 81171047. A04 THE INFLUENCE OF SMOKING ON THE POSTOPERATIVE OPIOID REQUIREMENTS OF PATIENTS UNDERGOING ROUTINE CESAREAN SECTION T.L. Hunt II, B. Hoelzer, T. Weingarten Divsion of Pain Medicine, Mayo Clinic, Rochester, MN, USA Introduction: Nicotine has long been known to have analgesic properties in both human and animal experimental pain models. Furthermore in some studies, nicotine administration in nonsmokers has been shown to have an analgesic effect on post-surgical pain. Paradoxically, tobacco use is associated with greater pain intensity and functional impairment in chronic pain disorders. There are several reports in the literature that report that smokers have greater post-operative pain and opioid requirements than nonsmokers. This case series investigates this relationship in healthy parturients who are undergoing routine cesarean section. Materials and methods: We conducted a retrospective chart review of 58 patients that underwent routine caesarean section with spinal anesthesia at Mayo Clinic. An in depth review of the subjects' medical, surgical and anesthetic records ware performed which resulted in six patients who met the stringent inclusion criteria. Primary end-point was total daily oral morphine equivalents forty-eight hours after surgery. Secondary endpoints included nausea, pruritus, pain scores, and hospital days. Results: There was a greater than four-fold increase in opioid requirements by total dose and dose / weight over forty-eight hours in the patients identified as smokers. Their pain scores were relatively higher in the smoking group despite increased opioid consumption. Discussion: Nicotine may contribute to increased opioid requirements in healthy parturients undergoing routine cesarean section. A larger study should be considered to further investigate this potential relationship. References: Flood, P. Intranasal Nicotine for Postoperative Pain Treatment. Anesthesiology. December 2004 Volume 101 - Issue 6 - pp 1417-1421 Habib AS. Transdermal nicotine for analgesia after radical retropubic prostatectomy. Anesth Analg. 2008 Sep;107(3):999-1004. Hong D. Transdermal nicotine patch for postoperative pain management: a pilot dose-ranging study. Anesthesia & Analgesia, 2008 Vogt MT. Influence of smoking on the health status of spinal patients: The National Spine Network Database. Spine 2002; 27:313-319. Weingarten TN. Impact of tobacco use in patients presenting to a multidisciplinary out- patient treatment program for fibro- myalgia. Clinical Journal of Pain 2008 Weingarten TN. An Assessment of the Association Between Smoking Status, Pain Intensity, and Functional Interference in Patients with Chronic Pain. Pain Physician 2008; 11:643-653 Yunus MB. Relationship between fibromyalgia features and smoking. Scandinavian Journal of Rheumatology 2002; 31:301-305 Creekmore F. Postoperative Opiate Analgesia Requirements of Smokers and Nonsmokers. Ann Pharmacother June 2004 vol. 38 no. 6 949-953 Olson LC. A Transdermal Nicotine Patch Is Not Effective for Postoperative Pain Management in Smokers: A Pilot Dose-Ranging Study. A & A December 2009 vol. 109 no. 6 1987-1991. Personal conflicts of interest disclosure: Each author warrants that there are no commercial associations that might pose a conflict of interest in connection with the submitted article. A05 VARIABLES IMPACTING THE EFFICACY OF REGIONAL NERVE BLOCK FOR POSTOPERATIVE PAIN MANAGEMENT IN TOTAL KNEE ARTHROPLASTY (TKA) PATIENTS: A RETROSPECTIVE STUDY Q. Liu, J.E. Chelly, M.S. Gold University of Pittsburgh Medical Center, Pittsburgh, PA, USA Introduction: Continuous nerve blocks have been demonstrated to provide more effective perioperative pain control than PCA opioid in orthopedics (Richman et al., 2006; McFarlane et al., 2009) However, protocols of local anesthetic administration do not account for the possibility that pathological conditions may influence the expression, distribution, and/or biophysical properties of sodium channels (Amir et al., 2006), and therefore LA requirement. To begin to explore this possibility, we performed a retrospective study of patients undergoing TKA at a hospital with a wellestablished protocol for post-operative analgesia to assess the impact of pre-existing conditions on LA usage. Materials and methods: Data were extracted from electronic medical records of patients who underwent unilateral primary total knee replacement (TKA) and TKA revision (TKA-R) performed at UPMC Shadyside hospital over a period of 18 months. The post-operative analgesia protocol was based on a combination of narcotics delivered via PCA, supplemented with PO narcotics, and regional anesthesia achieved with continuous femoral (0.0625% bupivacaine, 5 ml/h) and sciatic (0.03% bupivacaine, 3 ml/h) infusions that could be supplemented to a max of 3 ml/h. Resting pain was estimated from the average VAS score, while pain with activity was estimated from the VAS associated with physical therapy. Cumulative narcotic and LA use was determined. A priori hypotheses were tested with one- and two-way ANOVAs with post-hoc analysis as appropriate. Results: While pain scores and narcotic use were comparable in TKA (n = 994) and TKA-R (n = 232) patients, LA use was significantly higher TKA-R patients, particularly on post-operative day 1 (POD1). Pain scores were higher, and LA use was higher (close to the theoretical maximum) in patients (n = 7) undergoing TKA-R because of infection than either TKA or the remaining TKA-R patients on POD1. Comparable results were obtained when data were analyzed as a function of the presence of diabetes and/or diabetes with polyneuropathy (DPN), with LA use elevated in DPN patients undergoing TKA (n = 19) and TKA-R (n = 5), with the latter again close to the theoretical maximum. LA was also elevated in diabetic patients without complications (n = 67) undergoing TKA-R compared to their non-diabetic counterparts. There was no significant influence of obesity (BMI > 31) on pain, narcotic or LA use. Nor was there a detectable influence of surgeon, age or sex on these variables. Discussion: Our results suggest that there are subpopulations of patients, such as those undergoing TKA-R, who require more LA to achieve comparable levels of post-operative pain control. Additional subpopulations, such as those undergoing TKA-R for infection may be resistant to LA, and therefore may require alternative post-operative pain management strategies. Furthermore, there are subpopulations of patients such as those with diabetic neuropathy where there is not only an apparent 5 loss of LA efficacy, but who may also be more susceptible to LA-induced toxicity. This combination would constitute a patient subpopulation in which LA based peripheral nerve blocks are contraindicated. Ongoing work is focused on the identification of mechanisms underlying these apparent changes in LA efficacy. A06 THE THERAPEUTIC EFFECT OF REPEATED INTRATHECAL INJECTION OF IFENPRODIL ON BONE CANCER PAIN IN MICE Z. Ma, X. Gu, X. Yang, W. Zhang, Y. Liu Department of Anaesthesiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China Introduction: NR2B-contaning NMDA receptors play an important role in spinal dorsal horn nociceptive processing. Single intrathecal injection of ifenprodil, the most promising NR2B subunitspecific antagonist can reduce the pain in a mouse model of bone cancer pain. But the antihyperalgesic efficacy achieved maximum at 2 h after intrathecal administration of ifenprodil and 1 disappeared at 24 h . So the aim of the present study was to evaluate the effects of repeated injection of ifenprodil on bone cancer pain and the expression of NR2B protein in L3-L5 lumbar spinal cord segments in the mouse model. Material and methods: All experiments were approved by the Animal Care and Use Committee at the Medical School of Nanjing University. 96 male C3H/HeJ mice were divided randomly into tumor group (Group T), control group (Group C) and sham group (Group S). Osteosarcoma NCTC 2472 cells were implanted into the intramedullary space of the right femurs of mice in group T and C to induce ongoing bone cancer pain. Mice in group S were inoculated by α-MEM without cells. On 14d after inoculation, Group T were treated by intrathecal injection of ifenprodil 10µg (dissolved in 5µl 20% DMSO) once daily for three consecutive days. Group C and Group S were treated by intrathecal injection of 5ul 20%DMSO at the same time points. Pain behaviors such as the spontaneous lifting and the paw withdrawal mechanical threshold(PWMT) were observed on 1d before inoculation and on 3d, 5d, 7d, 10d, 14d, 17d, 19d, 23d after inoculation. Lumbar intumescentia of mice in each group was taken out to investigate the expression level of NR2B after pain behaviors tests at the corresponding time points. Results: On 14d after operation, the number of spontaneous flinches (12.33±1.98) was increased and PWMT (1.1±0.65)g was decreased in group T compared with group S (P< 0. 05). Consistent with the changes of pain behaviors, results of western blot showed that the expression of NR2B in L3-L5 lumbar spinal cord segments was increased significantly on 14d in group T (1.38±0.09) compared with group S (P< 0. 05). On 17d, 19d and 23d after operation, compared with the basal level of day14 before administration and group C, the number of spontaneous flinches ((6.38±1.41), (6.50±1.20), (7.63±1.07)) of group T were decreased, PWMT ((0.95±0.26)g, (1.00±0.30)g, (1.05±0.26)g) were increased, and the expression of NR2B ((1.17±0.03), (1.15±0.04), (1.15±0.05)) were decreased (P< 0.05). Discussion: Repeated intratheal injection of ifenprodil attenuated pain related behaviors and reduced the expression of NR2B in lumbar intumescentia in the mouse model of bone cancer pain. References: 1. Gu X, Zhang J, Ma Z, Wang J, Zhou X, Jin Y, Xia X, Gao Q, Mei F. The role of Nmethyl-D-aspartate receptor subunit NR2B in spinal cord in cancer pain. Eur J Pain 2010;14:496-502. Funding: This research was supported by National Natural Science foundation of China Grant no. 81070892 and 81171048. A07 EFFECTS OF INTRATHECAL INJECTION OF THE SMALL PEPTIDE INHIBITOR OF MLIN10PDZ1 DOMAIN ON THE BEHAVIORS OF BONE CANCER PAIN IN MICE Z. Ma, X. Gu, Y. Zhou, K. Ni, Y. Liu Department of Anaesthesiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China Introduction: The mLin-10 also named Mint1/X11, which belongs to the X11 family, is involved in the 1 transportation of proteins and neurotransmitters in neurons . Prelimilary studies have shown that 2 NR2B subunit plays an important role in the cancer pain . Vesicles containing NR2B subunit are 3 transported along microtubules by KIF17, a neuron-specific molecular motor in neuronal dendrites . Selective transport of NR2B is accomplished by direct interaction of the KIF17 tail with a PDZ domain 4 of mLin-10 . In this study, we used a synthetic peptide combining specifically with the mLin10-PDZ1 domain and inhibiting the interaction between KIF17 and mLin10, to investigate the role of the mLin10-PDZ1 domain in bone cancer pain . Material and methods: All experiments were approved by the Animal Care and Use Committee at the Medical School of Nanjing University. 40 male C3H/HeJ mice were randomly divided into five groups (n=8): group T, group G1, G2, G3 and group S. Osteosarcoma NCTC 2472 cells were implanted into the intramedullary space of the right femurs of mice in group T and G1-G3. Mice in group S were inoculated by α-MEM without cells. On day14 after inoculation, mice in group G1-3 were intrathecally injected of the small peptide inhibitor of mLin10-PDZ1 domain 2.5µg/5µl, 5µg/5µl, 10µg/5µl, respectively. Group S and T were intrathecally injected of 5µl 10%DMSO. Pain behaviors including the spontaneous flinches and the paw withdrawal mechanical threshold (PWMT) were observed. Results: Compared with group S, the number of spontaneous lifting (13.46±1.44) was increased and PWMT (1.83±0.23g) was decreased on day14 after inoculation in group T and G1-3 (P< 0.05). The number of spontaneous lifting was decreased, and PWMT was increased after intrathecal injection in group G1-3 compared with the base level on day14 and group T at the same time points (P< 0.05). The analgesic effects of group G3 was more conspicuous than group G1 and G2 (P< 0.05). Discussion: Intrathecal injection the small peptide inhibitor of mLin10-PDZ1 domain can efficiently relieve the bone cancer pain in mice. References: 1. Rogelj B, Mitchell JC, Miller CC et al. The X11/Mint family of adaptor proteins. Brain Res Rev 2006;52(2):305-15. 2. Gu X, Zhang J, Ma Z et al. The role of N-methyl-D-aspartate receptor subunit NR2B in spinal cord in cancer pain. Eur J Pain 2010;14:496-502. 3. Guillaud L, Setou M, Hirokawa N. KIF17 dynamics and regulation of NR2B trafficking in hippocampal neurons. J Neurosci 2003;23(1):131-40. 4. Setou M, Nakagawa T, Seog DH et al. Kinesin superfamily motor protein KIF17 and mLin-10 in NMDA receptor-containing vesicle transport. Science 2000;288(5472):1796-802. Funding: This research was supported by National Natural Science foundation of China Grant no. 81171048. A08 ROLE OF MIRS IN THE DEVELOPMENT OF SUSTAINED NEUROPATHIC PAIN FOLLOWING A PERIPHERAL NERVE INJURY M. Norcini, A. Sideris, L.A. Martin Hernandez, T.J.J. Blanck, E. Recio-Pinto 1 2 3 Anesthesiology, Anesthesiology, Physiology and Neuroscience, Anesthesiology , Pharmacology, NYU Langone Medical Center, New York, NY, USA Introduction: Chronic neuropathic pain following surgery is often associated with peripheral nerve injury. Unfortunately, adequate control of acute pain does not always lead to a decrease in the occurrence of chronic neuropathic pain. Peripheral nerve injury alters the expression of hundreds of proteins in the dorsal root ganglia (DRG). Many of these proteins have been found to contribute to the injury-induced development of chronic neuropathic pain. Targeting some of these proteins has led to successful treatments for acute pain, but not for preventing or treating sustained postoperative neuropathic pain. Treatment of chronic neuropathic pain may require the alteration of multiple proteins. Since a single miR can affect the expression of many proteins, we have attempted to identify miRs that could be used as targets for preventing the development of sustained postoperative neuropathic pain. Materials and methods: Adult rats undergoing sciatic nerve tibial- or sural-spared nerve injuries (Tibial-SNI, Sural-SNI) were used. The time course of mechanical (Von Frey) and cold allodynia (acetone test) was measured over a 3 month period. Total RNA isolated from individual L4- and L5DRG was used for miR microarrays analysis. TargetScan and Miranda software was used to identify potential mRNA targets. The list of potential mRNA targets was limited to those encoding for ion channels, neurotransmitter receptors and other proteins known to be important for normal neuronal excitability. Results: To increase the probability of detecting pain-specific deregulated miRs, we compared the animal behavior and the DRG miR pattern of Sural- and Tibial-SNI animals. The two SNI variants initially displayed strong mechanical allodynia, but behavioral discrepancies emerged: Sural-SNI animals maintained strong mechanical and cold allodynia, while Tibial-SNI animals recovered from mechanical allodynia and never developed cold allodynia. We found that the levels of most of the detected miRs (>180) in L4- and L5-DRG were altered following either SNI variant; however, only 8 miRs were uniquely altered in one of the SNIs or in the opposite direction in both SNIs. The targets of these 8 miRs include mRNAs encoding for various ion channels including pacemakers, voltagedependent sodium, calcium and potassium channels. Discussion: The expression of most of the miRs in DRG are affected following either peripheral nerve injury variant. However, only 8 miRs were differentially modulated between the two SNI injuries. Based on their identified and predicted mRNA targets, a decrease in the expression of any of 4 of the identified miRs may lead to an increase in neuronal excitability in Sural-SNI DRG neurons; while an increase in the expression of any of 7of the indentified miRs may lead to a decrease in neuronal excitability in Tibial-SNI DRG neurons. The predicted miR-mediated increase in neuronal excitability correlates with the development of sustained neuropathic pain in Sural-SNI; while the predicted miRmediated decrease in neuronal excitability correlates with the recovery from early neuropathic pain in Tibial-SNI. Additional studies are being done to investigate whether alteration of the expression of any of the identified miRs in vivo can be used to prevent or treat sustained postoperative neuropathic pain. A09 DOES SUTURING IMPROVE THE RATE OF SUCCESSFUL REACTIVATION OF LABOR EPIDURAL CATHETERS FOR POSTPARTUM TUBAL LIGATION (PPTL) SURGERY S. Shah, S. Cohen, A. Mohiuddin, M. Fernandez, C. Kloepping, P. Shapiro, S. Mungekar, C.W. Hunter Anesthesiology, Robert Wood Johnson University Hospital-UMDNJ, New Brunswick, NJ, USA Introduction: Ninety two percent of lumbar epidural catheters for labor pain remained in place until 1 the time of PPTL Surgery can be reactivated successfully until 24hrs after they have been placed . 2 Suturing the epidural catheter in our previous study , reduced catheter movement, the need for re insertion, the incidence of one sided anesthesia and epidural vessel puncture and provided a high success rate of epidural blocks. Methods: Following IRB approval and informed consent, we studied 121 ASA I-II patients scheduled for PPTL with epidural catheter in place. Of 2400 parturients who received epidural analgesia for labor pain and were randomized into 1200 patients who had the epidural sutured and 1200 that had catheter without suture, two groups were identified. Group I (N=48) had their catheters sutured upon insertion. Group II (N=73) had their catheters secured without suture. The epidural space was located at L2,3 using LOR to air technique and a midline approach with the patient in lateral or sitting flexed position. An 18g “B Braun” ( B.Braun Medical Inc., Bethlehem PA18018) closed end tip catheter was directed 5 cm cephaled. For Group I parturients, the cathters were sutured with 3-0 vicryl suture at the insertion site and then looped downward 5 cm. Group II parturients had their epidural catheters looped downward 5 cm without being sutured. Mastisol glue and transparent dressing were then applied. An investigator recorded the patient's age, height, weight, parity, position for insertion of catheter, distance of epidural space from skin and previous history of epidural block , spinal block, spinal tap, dural puncture or blood patch. Also recorded were incidence of failed epidural block (a properly functioning epidural block which subsequently failed) catheter dislodgment, blood vessel puncture, dural puncture, need for catheter readjustment or reinsertion, occurrence of unilateral block, maximum lumbar sensory level, Bromage Score (1=complete motor block, 5=no weakness of hip flexion) catheter position and length of catether coiled under the skin at the time of catheter removal, and overall satisfaction (0 = worst, 10=best). Results: Groups did not differ in age, weight, height, parity, distance of epidural space from the skin, position, history of previous neuraxial procedure, Bromage Score, maximum sensory level. Overall satisfaction was high in both groups, 9.6+0.9 vs.. 9.5+1.0 for Groups I and II respectively. The length of catheter coiled under skin upon removal was 0.5+0.7cm and 0.2+0.6cm ( p < 0.05 Student's unpaired test). The incidence of catheter movements and resulting complications and corrections are shown in Tables I & II respectively. Of the 12 failed blocks in group II, 3 occurred within 4 to 12 hours(4%), 7 within 12 to 24 hours(10%) and 2 after 24 hours(3%). Catheter Movement Outward Catheter Movement Inward Catheter coiled Subcut Dislodged Group I 7(14%) 4(8%) 0.5 ± 0.7 0 Group II 26(36%) 13(18%) 0.2 ± 0.6 11(15%) [Table I] Failed Block One-sided Anesthesia Blood Vessel Puncture Readjustment of Catheter Reinsertion of Catheter Catheter Kink Group I 0 0 0 2(4%) 0 1(2%) Group II 12(16%)* 5(7%) 1(1%) 4(5%) 0 1(1%) [Table II: Incidence of Complications and Correctio] Conclusion: Suturing the epidural catheter for labor pain increased the success rate of reactivation of epidural block for PPTL, reduced catheter movement and need for reinsertion, decreased the incidence of one-sided anesthesia and catheter puncture of epidural vessels. References: 1. Goodman EJ et al. Reg Anesth 23: 258 - 261, 1998 2. Cohen S et al. Anesthesiology 89: A1065, 1998 A10 PROPHYLAXIS VERSUS THERAPEUTIC BLOOD PATCH FOR ACCIDENTAL DURAL PUNCTURE IN OBSTETRIC PATIENTS 1 1 2 1 1 1 1 S. Shah , S. Cohen , I.P. Lowenwirt , R. Chhokra , A. Mohiuddin , K. Dauphinee , S. Yeh , T. 1 1 Shkolnikova , C.W. Hunter 1 Anesthesiology, Robert Wood Johnson University Hospital-UMDNJ, New Brunswick, NJ, Anesthesiology, New York Hospital, Queens, NY, USA 2 Introduction: Therapeutic epidural blood patch (TEBP) is a standard of care of treatment of postdural puncture headache (PDPH). Prophylactic epidural blood patch (PEBP) has been recommended for accidental dural puncture in order to eliminate or reduce the incidence of PDPH and more serious complications of dural puncture: hearing loss, diplopia and tinnitus. However, this treatment is not commonly accepted. Objective: In this prospective randomized study we compared the efficacy of a PEBP with TEBP in preventing PDPH and its complication in obstetric patients. Method: Following IRB approval, obstetric patients with accidental dural puncture from 16g or 17g needles were randomized and allocated to two treatment groups. Group I (n=54 PEBP Group) patients received 15-20 autologous blood through the indwelling epidural catheter at least 5 hours following the last dose of local anesthetic for labor cesarean delivery then the epidural catheter was removed. Group II: ( n = 54 TEBP ) did not receive blood through the catheter. These patients were managed conservatively with IV hydration, bed rest, theophylline or caffeine. When PDPH and/or its complications developed, a TEBP was performed at patients request with 15-20 ml autologous blood via an epidural needle. An independent investigator evaluated all patients at 12-hour intervals, prior to discharge and then by phone for one week. Patients were instructed to contact the anesthesiology department if they developed PDPH or its complications at any time later. Headache (HA) was rated on a scale of 0-3 (0=no HA, 3=severe HA). Treatment failure was defined as HA scale of 3 following EBP in either group which required a second EBP. Results: Groups did not differ in age, height, weight or parity. PEBP was successful in 80% (n=43) of patients (Table I) and only 6 (11%) patients required a second BP while 26% (n=14) of TEBP were asymptomatic following conservative treatment and did not require EBP. Furthermore, of the control TEBP Group, 3 patients (5.6%) developed diplopia, and 5 patients (9%) required a second blood patch. 5 patients (9%) from Group I vs. 10 patients (18.5%) from Group II required emergency room visit for severe HA after discharge. No patient in either group developed complications from EBP. Duration of hospital stay was 3.4+1.5 & 3.0+1.3 days for Group I & II respectively. Prophylactic blood patch is a simple and safe technique associated with a good success rate (80%) in preventing PDPH and its complications with less patients suffering and with reduced morbidity after accidental dural puncture. [Table I: Complications from Dural Puncture] Conclusions: Prophylactic blood patch is a simple and safe technique associated with a good success rate (80%) in preventing PDPH and its complications with less patients suffering and with reduced morbidity after accidental dural puncture. Reference: 1. Anesth Analg 1989; 69:522-3. A11 RATS WITH FEATURES OF METABOLIC SYNDROME EXHIBIT SEX-SPECIFIC DIFFERENCES IN NOCICEPTION 1 2 1 1 1 1 2 M. Sternberg , A. Mirra , N. Cheng , C.J. Watson , L. Koch , S. Britton , G. Vesce , R. Lydic 1 1 2 Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA, Department of Clinical Veterinary Science, Università degli Studi di Napoli Federico II, Naples, Italy Introduction: Pain processing is polygenically modulated and varies as a function of sex, body habitus, modality, and genotype. Human pain has been positively correlated with obesity (J Pain 8: 430, 2007) and both pain processing and self-reports of pain vary between men and women (J Pain 13: 228, 2012; J Pain 101: 259, 2003). Rats selectively bred to have features of metabolic syndrome (Science 307: 418, 2005) may provide an animal model that can help elucidate the underlying neurochemical mechanisms contributing to differences in pain that are sex-specific and associated with obesity/metabolic syndrome (Anesthesiology 113: 1176, 2010). As an initial step prior to pharmacological studies of chronic pain, this experiment is testing the hypothesis that rats with features of metabolic syndrome exhibit sex-specific differences in nociception. Materials and methods: To date we have used multimodal pain testing to evaluate nociceptive responses in male (n = 3) and female (n = 3) rats with features of metabolic syndrome. The experiments quantified hind paw withdrawal latency to a heat stimulus using the Hargreaves method (Pain 32: 77, 1988). Gram-equivalent responses to mechanical stimuli were quantified using the updown method (J Neurosci Methods 53: 55, 1994). Duration of response to the acetone spray test was used to characterize the response to a cold thermal stimulus (Anesth Analg 101: 457, 2005). Results: Responses were quantified (mean ± SD) for male and female rats on each of the three pain modalities tested. Paw withdrawal latencies (PWL) in seconds for females (7.26 ± 1.45) and males (5.98 ± 1.51) differed by 21.4%. Responses to mechanical stimuli (in grams) for females (8.66 ± 6.35) and males (5.40 ± 5.21) differed by 60.4%. Duration of response to the acetone spray test in seconds for females (0.5 ± 0) and males (0.67 ± 0.26) differed by 33.3%. Discussion: Previous studies found that lean rats selectively bred for enhanced aerobic fitness had higher thresholds for heat nociception than did rats bred to promote features of metabolic syndrome (Neurosci Lett 443: 37, 2008). Lean/fit rats also recover more rapidly from neuropathic pain caused by chronic constriction injury of the sciatic nerve (Anesthesiology 113: 1176, 2010). The present results indicate that in obese rats with features of metabolic syndrome the females had a longer PWL, a greater threshold for mechanical nociception, and a longer duration of response to the acetone test. These data imply a lower pain threshold in the obese, male rats. The preliminary results also suggest that rats selectively bred to enhance the polygenic modulation of obesity/metabolic syndrome offer a unique resource for studies aiming to elucidate mechanisms contributing to sex-specific differences in nociceptive processing. A12 THORACIC EPIDURAL ANALGESIA FOR POSTOPERATIVE PAIN MANAGEMENT AFTER PECTUS EXCAVATUM AND PECTUS CARINATUM REPAIR S. Turial, V. Kelsch, F. Schier Pediatric Surgery, University Medical Center Mainz, Mainz, Germany Purpose: The aim of the present retrospective study was to investigate the efficacy and safety of the thoracic epidural analgesia (TEA) for the pain control after surgical correction of chest wall deformities in adolescents. A comparison of the results to a historical group of patient-controlled analgesia (PCA) after identical surgical procedures is provided. Methods: Patients treated for pectus excavatum or carinatum (Nuss or Ravitch procedures) in the last three years at our institution were randomly assigned to receive TEA for postoperative pain control. Demographic and clinical data (body weight, age, sex, Haller index, operative time and course), pain related data and complications (the incidence of catheter-related complications or adverse events of treatment such as nausea, vomiting, and respiratory depression) were collected prospectively. Pain was assessed every 4 to 8 hours on a visual analog scale by the nurses based on a standardized regime. Daily use of analgesics was also recorded for the total time of hospital stay. For the purposes of the present study, a retrospective data analyze was performed and the results were compared to a historical cohort of patients which received patient-controlled analgesia (PCA) after the same kind of surgeries. Results: During the study period 22 patients (average age: 17.3years, 14 male, 8 female, 15 Nussprocedures, 7 Ravitch-procedures) received TEA. The epidural catheter could not be placed in three patients and was removed within 24 hours in 2 patients. No serious complications related to the catheter placement were noted. On average the PCA devices were maintained for 5.3 days and TEA for 4.7 days, respectively. Serious attacks of vomiting and nausea were noted in 64 % in PCA group and in 30 % of TEA group. Respiratory depression symptoms occurred in 42 % of the PCA group and in 10 % of the TEA group, respectively. The patients in TEA group were mobilized 1.5 days after surgery on average. In contrast the patients with CPA were mobilized, on average, after 4.5 days postoperatively. Conclusion: Both the TEA and the PCA provide effective postoperative pain relief after surgical repair of chest wall deformities. PCA caused severe side effects in the majority of patients in comparison to the TEA. In addition, the TEA enables an early patient mobilization and provides high level on patient comfort. A13 FLUOROSCOPIC GUIDANCE DECREASES THE MECHANICAL FAILURE RATE OF THORACIC EPIDURAL CATHETERS USED FOR POSTOPERATIVE PAIN CONTROL K. Washburn, M. Yeager, P. Barr, A.K. Bonham, R. Loftus, M. Parra Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA Introduction: Postoperative thoracic epidural analgesia is a common and effective technique for control of post-thoracotomy pain. However, blind placement of thoracic epidural catheters has a substantial failure rate (1,2). Routine use of flouroscopic guidance to place thoracic epidural catheters is a relatively new approach with unproven efficacy. Materials and methods: With IRB approval and following written informed consent, we randomized patients scheduled for open thoracotomy to have an epidural catheter placed before surgery for postoperative analgesia with either; a) fluoroscopic guidance (F) or b) via a traditional (T) ´blind´ technique (no fluoroscopy). In the experimental group F, the epidural space was entered at the T6T10 level using loss of resistance (LOR). An epidural catheter was then threaded under fluoroscopic guidance to place the tip of the catheter at the body of T4. Following injection of a test dose of local anesthetic, an epidurogram was obtained using 5ml dye to confirm epidural placement. In the control group T, the T6 vertebral level was identified using anatomic landmarks and the epidural space identified using LOR. An epidural catheter was then inserted 5cm after which a test dose of local anesthetic was injected. Patients in both groups then received a continuous infusion of 1/8% bupivacaine at 4 ml/hr. Patients in both groups were followed and managed postoperatively by an Acute Pain Service team of doctors and specialty nurses who followed a pre-identified catheter use algorithm. Results: 45 patients were randomized (23 F, 22 T). In Group T, the average duration of catheter use was 62.3 (+/- 24 S.D.) hours which was not different from Group F, where the average duration of catheter use was 67.4 (+/- 29 S.D.) hours. In Group T 5 of 22 catheters (23%) were removed due to mechanical loss of function (leakage, dislodgement) while 0/23 catheters in Group F had mechanical failure. Discussion: Previous prospective studies of epidural catheters in place for postoperative pain control have reported failure rates similar to the Group T failure rate of 23% due to mechanical loss of function (1,2). In this analysis, we did not find that the average duration of epidural catheter use after surgery was significantly affected when catheters were placed under fluoroscopic guidance. Many factors other than catheter function affect duration of catheter use including duration of chest tube placement, extent of surgery, bleeding, etc. We did, however, find that the mechanical failure rate that has been reported by other groups (13 to 24% [1-3]) appeared to be improved probably due to confirmation of epidural location and greater insertion depth of catheters when they are placed under direct X-ray guidance. References: 1. Anesth Analg. 2006 Oct;103(4):1026-32.) 2. Anaesth Intensive Care. 1998 Apr;26(2):165-72. 3. Anaesthesia. 2001 Jan;56(1):75-81. No authors report a financial conflict of interest. A14 E-LEARNING, A 3D LEARNING MODULE OF THE BRACHIAL PLEXUS DEPICTING ANATOMY RELEVANT TO REGIONAL ANESTHESIA CAN BE AN EFFECTIVE EDUCATIONAL RESOURCE K.P. Armstrong, J. Turgeon, T.D. Wilson 1 2 Department of Anesthesia and Perioperative Medicine, Anatomy and Cell Biology, CRIPT Lab, Western University, London, ON, Canada Introduction: Digital learning resources have increased in number and manner of access (1,2) for almost all allied health fields. These resources may improve the understanding of specific anatomy (2). In some instances, simple digital models may be adequate. However, anatomically, functionally, and spatially complex models may represent one area where 3D visualization may be more appropriate in other situations. We hypothesize that 3D digital learning resources of the BP can improve anatomical understanding and knowledge for learners. Material and methods: A 3D BP digital model was developed using the Visible Human Dataset and digital segmentation techniques (3). Anatomical data related to regional anesthesia was presented as interactive online modules (figure 1). The modules were designed in guided (G) and self guided (S) formats (3). Points of emphasis included structure, neural contribution, spatial relationships, potentially vital structures, etc. Participants included allied health students and anesthesia residents. All participants completed an anatomical pretest enabling classification of high (H) or low (L) “knowledge groups”. Using identical learning objectives, participants were assigned to one of 4 groups HS, HG, LS, LG. Following completion of the module, a post-test was administered. Subjects completed evaluations of the model and provided feedback on their experience. Descriptive statistics and one-way analysis of variance (ANOVA) were used to compare pre-test scores, post test scores, and the relationship of prior knowledge and information acquisition. Likert responses for subjective evaluations were grouped as generally negative (disagreed and strongly disagreed), or positive (agreed and strongly agreed) scores. Results: Exposure to the model led to improved post test when compared to the pre-test scores (figure 2). Low knowledge individuals when exposed to guided version of the learning module where found to have the greatest improvement . Subjective evaluations were supportive of this learning tool (table 2). Discussion: Pre- and post exposure testing suggest that this model is effective for learning BP anatomy relevant to regional anesthesia at all levels of expertise, significantly so in HG, LS, LG learning groups. The novice learners may benefit most from a guided format. Further work to evaluate learning strategies of virtual learning environments is required. [Figure 1. Brachial plexus module images] [Figure 2. Mean score pre and post test scores ± SD] Treatment Paths Feedback Survey Statements HS (n=12) HG (n=11) LS (n=8) LG (n=7) response - + - + - + - + S9. I found this module was an effective way to learn 0 100 0 100 0 100 0 71 S10. Overall this model contributes to my knowledge of the brachial plexus 0 92 0 100 0 100 14 86 S11. Prior to this module I was comfortable with my knowledge of the brachial plexus 33 42 18 45 50 13 71 14 S12. This module was applicable to my course or field of study 0 92 0 100 0 0 86 100 [Table 2. Responses provided by participants] References: 1. Drake et al. Medical education in the anatomical sciences:. Anatomical Sciences Education 2009; 2(6):253-259 2. Khalil et al. Using computer‐based interactive imagery strategies for designing instructional anatomy programs. Clin Anat 2005;18(1):68-76 3. Turgeon et , User experience and its influence on the evaluation of information presentation in an online learning module. American Association of Anatomists, San Diego CA. April 2012. Funding: Department of Anatomy and Cell Biology A15 SUPPLEMENTARY ULNAR NERVE BLOCKADE EXTENDS ANALGESIA IN PATIENTS RECEIVING SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK FOR ULNAR DISTRIBUTION HAND SURGERY J.P. Cameron, B.C.H. Tsui, J.C. Leung, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Hand surgery in our institution is most commonly performed under regional anesthesia. 1 Post-operative pain is a common occurrence after this type of surgery. Previous studies have shown improved intra-operative anesthesia and post-operative analgesia in patients undergoing proximal 2,3 brachial plexus blockade plus multiple terminal nerve blocks. This study examined whether prolonged analgesia was achieved after supraclavicular brachial plexus blockade plus a supplementary ulnar nerve block versus supraclavicular block alone for patients undergoing hand surgery in the ulnar distribution. Material and methods: After institutional ethics approval, adult elective day-surgery patients undergoing surgery on the fourth and/or fifth metacarpals and/or phalanges were recruited to the study. Patients randomized to the control group received a standard ultrasound-guided supraclavicular block using 25-30 mL of 1.5% lidocaine + 0.125% bupivacaine. Patients in the study group received a reduced-volume ultrasound-guided supraclavicular block of 20 mL 1.5% lidocaine + 0.125% bupivacaine plus an ulnar nerve block using 5 mL of a 0.5% ropivacaine + 0.125% bupivacaine solution. Block performance time was recorded, and patients were contacted the following day to assess the onset of sensation and movement in the affected limb as well as maximum numerical rating scale pain score. Results: Twenty-five patients were recruited to the study; five were lost to follow up, leaving ten in each group. On average, total time to perform the block(s) was longer for the combined block patients than the supraclavicular-only patients (13.3 ± 7.5 min vs. 10.7 ± 4.8 min), but not significantly so (p=0.36). Patients who received a combined block experienced later onset of pain compared to the control group (525.8 ± 238.9 min vs. 296.3 ± 61.3 min; p=0.014). Time to maximal pain sensation was also longer in the combined block group (621.8 ± 282.7 min vs. 363.8 ± 82.9 min; p=0.019). The average pain intensity after recovery of sensation was similar between the two groups (6/10 study group vs 6.6/10 control group). Discussion: Administering a supplementary ulnar nerve block in addition to a supraclavicular block did not significantly extend block performance time and provided, on average, over three hours more pain relief compared to patients receiving a standard supraclavicular block. These results suggest that administration of an ulnar nerve block in addition to a low-dose supraclavicular block is an efficient and effective method of providing pain relief in the 24 hours following hand surgery in the ulnar nerve distribution. References: 1. Rawal N, et al. Anesth. Analg. 2001; 92: 347-51. 2. Smith BE, et al. Anaesthesia 1989; 44: 747-9 3. Fredrickson MJ, et al. Br. J. Anaesth. 2011; 107: 236-42 Funding disclosure: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Partial funding was provided by the Estate of the late Mildred R. Weston. Personal conflicts of interest disclosure: Nothing to disclose. A16 THE ANALGESIC EFFICACY OF THE TRANSVERSALIS FASCIA PLANE BLOCK IN ILIAC CREST BONE GRAFT HARVESTING J. McVicar, H. Murgatroyd, A. Bhatia, B. Graham, V. Chan, K.J. Chin 1 2 Anesthesiology, Hand Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada Background: Iliac crest bone graft (ICBG) harvesting is associated with significant postoperative pain. The Transversalis Fascia Plane (TFP) block is a novel technique targeting the subcostal, 1 ilioinguinal and iliohypogastric nerves that innervate the anterior iliac crest (Figure 1) . Local anesthetics are injected into an interfascial plane between the deep investing fascia of transversus 2 abdominis and the transversalis (Figure 2) . [Ultrasound Guided TFP Block] [Sensory innervation of the anterior iliac crest. ] Our objective was to determine whether an ultrasound (US)-guided TFP block provides effective analgesia following ICBG harvesting. Methods: We recruited adult patients undergoing ICBG harvesting and elective upper limb surgery performed under brachial plexus block. Patients were randomized to receive an US-guided TFP block with 20ml 0.5% ropivacaine with 1:200 000 epinephrine or 20ml of 5% dextrose solution (placebo). Patients also received either a general anesthetic (GA) or spinal anesthetic according to their preference. Opioids were administered in the operating room and the post anesthesia care unit (PACU) at the discretion of the attending anesthesiologist. All patients were admitted to hospital overnight and received IV PCA morphine. Results: The data from 30 patients is presented. There were no differences in patient population in terms of age, sex, BMI or surgery type. 53% of patients received the US-guided TFP block and 50% underwent GA. Results are presented in Table 1. TFP Placebo P Value Pain Scores (0-10 visual analogue score (VAS)) VAS @ PACU admission 0 (0-0) 3 (0-7) 0.008 VAS @ PACU discharge 0 (0-2) 2 (1-5) 0.013 Average VAS in 1st 24h 2 (0-4) 4 (3-7) 0.026 Average VAS in 24-48h 2 (0-3) 4 (2-5) 0.057 Opioid Consumption (IV morphine equivalents in mg) In PACU 0.5 ± 1.4 5.1 ± 4.9 0.002 PCA at 4h postoperative 1.2 ± 2.3 7.1 ± 6.5 0.004 PCA at 8h postoperative 6.6 ± 9.9 16.5 ± 9.9 0.035 [Opioid Use & Pain Scores at ICBG Harvest Site] The intervention group had significantly lower pain scores at the hip in the PACU, and at 24 and 48 hours postoperatively. Opioid consumption was also significantly lower in the intervention group in the following time periods: intraoperatively, in PACU, and at 4 hours and 8 hours post-operatively. There was, however, no difference in total IV PCA morphine consumption. Discussion: The TFP block provides effective analgesia at the ICBG harvest site, with discernable effects up to 24-48h postoperatively. There was significant reduction in perioperative opioid consumption up to 8h postoperatively in the intervention group. Total IV PCA morphine consumption was similar between groups but we attribute this to pain at the primary surgical site once the brachial plexus block had worn off. References: 1. Hebbard PD. Transversalis fascia plane block, a novel ultrasound- guided abdominal wall nerve block. Can J Anesth 2009; 56: 618-20. 2. Chin KJ et al. Ultrasound-guided transversalis fascia plane block provides analgesia for anterior iliac crest bone graft harvesting. Can J Anesth 2012 59:122-123. A17 PATIENT SIMULATION IMPROVES ANESTHESIOLOGY RESIDENTS' ABILITY TO MANAGE LOCAL ANESTHETIC SYSTEMIC TOXICITY AS MEASURED BY WRITTEN AND CLINICAL ASSESSMENT 1 1 2 1 B. Elmore , B. Ginter , J.-M. McGaugh , J. Dority 1 2 Department of Anesthesiology, University of Kentucky, Lexington, KY, University of New England College of Osteopathic Medicine, Biddeford, ME, USA Introduction: Patient simulation as a training technique allows learners to become familiar with complex and rare facets of medical care with increased understanding of less-common complications and improved patient safety. Recent studies suggest local anesthetic systemic toxicity (LAST) has an incidence of 0.8-1.0/1000 regional blocks, making training in recognition and management of this high-mortality complication ideally suited to simulation. Here we assess the use of the patient simulator (PS) to enhance the training of residents in the management of LAST. A knowledge deficit was identified in the learners' ability to recognize symptoms and initiate proper therapy. We demonstrate better understanding and retention of key concepts when using simulation compared to standard lecture only. Methods: Anesthesia residents were organized into two groups. The first group participated in a PS with LAST complicating an interscalene block. In the scenario the patient expresses anxiety that progresses to seizure and cardiovascular collapse. The resident is expected to recognize the signs of LAST and manage the patient appropriately. Two independent observers assessed the simulation performance using an objective structured clinical examination (OSCE) based on a modified ASRA checklist for treatment of LAST. Following the simulation encounter, residents' knowledge of LAST was evaluated through a computerized pre-test. An anesthesiologist then explained management of LAST during a 10-minute discussion period. Afterwards, the resident completed a second simulation to reinforce concepts and foster retention. Finally, a post-test was administered followed by a Likert scale survey for self-assessment of the activity. The second group proceeded directly to the pre-test. Next, a 10-minute recorded lecture on LAST management was shown to the resident. Residents were then administered the post-test and survey. In two months, each participant will return for evaluation of LAST management concept retention using a new PS with a checklist, post-test, and self-evaluation survey. Results: [Figure 1] Figure 1. Average Percent Correct OSCE Items Pre- and Post-Discussion. [Figure 2] Figure 2. Average Percent Correct Items on Pre- and Post-Test. (Error bars represent one standard deviation for both figures) Figure 1 demonstrates immediate improvement in clinical skills as evaluated by our OSCE after our discussion of LAST management in simulation. Figure 2 reflects similar improvement in knowledge base. Subjective self-assessment (not included) also shows increased resident confidence in ability to manage LAST after simulation and preference for simulation training. Discussion: PS provides residents with an opportunity to trial high-stress situations and rare events without placing patients at risk. Our initial data indicate that residents show significant improvement in their ability to manage LAST after simulation training when compared to didactic lecture alone. A poststudy exam and simulation will occur two months after primary teaching to allow comparative retention analysis. Additionally, our LAST simulation will be incorporated into our 'rare event' curriculum, which our department utilizes to simulate complex anesthetic cases such as cardiopulmonary bypass and one-lung ventilation to facilitate improvement in clinical ability. Funding Disclosure: None. Conflicts of Interest: None to disclose. A18 THE USE OF CEREBRAL OXIMETRY TO DETECT CEREBRAL DESATURATION EFFECTS IN ARTHROSCOPIC SHOULDER SURGERY IN THE BEACH CHAIR POSITION A. Francois, D. Salazar, B. Sears, P. Tonino, G. Marra 1 2 3 Anesthesiology, Orthopedics, Loyola University Medical Center, Maywood, IL, USA Introduction: The beach chair position for arthroscopic shoulder surgeries is widely used by orthopedic surgeons. This position has significant physiologic effects and can be a contributing factor in reduction of cerebral perfusion intraoperatively, causing cerebral hypoxia. Cerebral oximetry has been used in the surgical setting to monitor tissue oxygenation in the brain. In this study, we were interested in the clinical sequelae of cerebral desaturation events, as well as risk factors for cerebral desaturation in patients undergoing arthroscopic shoulder surgery in the beach chair position. Material and methods: With IRB approval and informed patient consent, Regional Cerebral Tissue Oxygenation (rSctO2) was measured in 50 patients undergoing arthroscopic shoulder surgery in the beach chair position, using Near Infrared Spectroscopy (NIRS) (INVOS 5100, Somanetics, Troy, MI). The patients were administered the Repeatable Battery for the Assesment of Neurophysiologic Status (RBANS) test preoperatively the day of surgery to obtain a cognitive baseline. Bilateral cerebral oximetry probes were placed for continuous monitoring. baseline noninvasive blood pressure and rSctO2 were measured prior to interscalene block. All patients also had general anesthesia with sevoflurane via LMA. rSctO2 was measured prior to induction, during patient positioning until the conclusion of surgery. Patients were positioned in the semi upright position 80 degrees from horizontal, with the head neutral. We defined a cerebral desaturation event (CDE) as a decrease in rSctO2 of 20% or greater from baseline, and this was treated with ephedrine in 5mg increments, or neosynephrine 80mg, crystalloid bolus, or returning the patient to supine. On postoperative day 3 when the patients returned to the clinic for follow-up and wound assessment, they were againg given the RBANS exam. Patients were randomized to receive a dissimilar version of the RBANS A, B, C or D from their preop exam. these were administered by research assistants trained in administration of the test. The association between any intraoperative CDE and the pre- and post-operative RBANS was assessed. Results: Complete data sets were obtained for 50 patients meeting inclusion criteria. Nine patients in our series had intraoperative desaturation events (18%) The RBANS did not demonstrate any measurable difference between the pre- and post -operative exams. There was no significant difference between the patients who experienced desaturation events and those who did not in regards to age, gender, smoking history, coronary disease, obstructive sleep apnea, diabetes, peripheral vascular disease or pulmonary disease. In 2 of the patients who experienced CDE below 20%, the procedure was temporarily suspended and the patients returned to supine to allow for correction of the desaturation. Discussion: Measurement of rSctO2 with NIRS can show when there is potential for mismatch between cerebral oxygen supply and demand. Since a threshold for rSctO2 is not known, NIRS allowed prompt identification and treatment of decreased cerebral perfusion pressure, preventing catastrophic outcomes. References: 1. Ghosh A, et al: Cerebral Near-Infrared Spectroscopy in adults. Anes Analg. 2012 Dec: 115: 137383 2. Pohl A. et al. Cerebra ischemia During Shoulder Surgery in the Upright Position. J. Clin. Anes. 2005: 17: 463-9 A19 ULTRASOUND GUIDANCE FOR BRACHIAL PLEXUS BLOCK DOES NOT AFFECT NERVE DISTORTION IN COMPARISON WITH NERVE STIMULATION 1 2 2 J. Geerling , M. Harbell , P. Aleshi , P. Hess 1 1 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 2 Boston, MA, Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA Introduction: Nerve injury after regional anesthesia is multifactorial. Nerve disruption due to needle or fluid infiltration is believed to be a risk factor. Animal studies suggest intraneural injection causing 1 nerve expansion results in histologic but not functional nerve injury . Ultrasound has been suggested to decrease risk of nerve injury by observation of needle placement and fluid injection. We hypothesized that ultrasound guidance would reduce nerve disruption and possibly nerve injury. Methods: After IRB approval and informed written consent, subjects underwent brachial plexus block (interscalene - axillary) using either nerve stimulation (NS) or ultrasound (US) guidance, with 0.375% bupivacaine and epinephrine 5mcg/ml. Onset time of motor and sensory blockade, duration of block, and postoperative pain were recorded. Ultrasound images were taken immediately before and after injection by a single observer. Images were reviewed by a blinded observer for location of the final injection, whether a circumferential 'donut' was produced, and the degree of nerve disruption by swelling or seperation, and were evaluated by ordinal scales and a 7-point Composite score. Block failures were eliminated from the analysis. Data were reported as median (quartiles). Comparisons were made using Mann-Whitney test, Fisher's exact, or Spearman correlation, as appropriate. Results: 122 subjects completed enrollment, 89 NS and 33 US. Patient who had NS were more likely to receive general anesthesia over sedation (74% vs. 52% P=0.03). No difference in onset of motor block (9min (8-14) vs. 9min (6-11) P=0.22), duration (19hr (14-23) vs. 17hr (12-23) P=0.08), or postoperative pain (0/10 in both groups) was found between NS and US, respectively. No difference was found between groups in the value for nerve distortion or circumferential donut, but Composite score was greater in the US group (3 (3-3) vs. 4 (3-5) P=0.03). Image scores correlated with each other, but not with sensory block, motor block or with block duration. In the US group, the circumferential donut score negatively correlated with duration (r=-0.46 p=0.02). No patient had nerve injury from the anesthetic procedure. [Comparison of US and NS blocks] Discussion: Both blind injection technique (nerve stimulation) and ultrasound guidance produced nerve bundle distortion and circumferential distribution of injected fluid. We were unable to distinguish the technique by the distribution of the injectate. Nerve disruption is common with either US or NS technique and did not appear to cause nerve injury. Furthermore, the visual evaluation of this spread did not predict the onset or duration of blockade. In the ultrasound group, intentionally attempting to create a donut outside of the bundle correlated with a shorter duration of blockade. In conclusion, regardless of the technique of injection, nerve disruption is common during brachial plexus block, but does not predict success or duration of the block. 1 Reference: Lupo CM.Histologic evidence of nerve injury with swollen nerve on US Reg Anesth Pain Med. 2010;35:132. Funding: Beth Israel Anesthesia Foundation Personal conflicts of interest disclosure Hess: consultation for Philips Ultrasound, Inc. A20 WRONG SITE BLOCKS: 10 YEAR EXPERIENCE IN A LARGE MULTI-HOSPITAL HEALTH CARE SYSTEM M. Hudson, J.E. Chelly, J.P. Williams Department of Anaesthesiology and Pain Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Introduction: Wrong site nerve block is considered a serious reportable event (SREs) in healthcare by the National Quality Forum (NQF) Board. Scarce reports based on anecdotal data have tried to quantify this complication but it's frequency remains unknown, along with associated risk factors. This study was conducted to assess the frequency of wrong site blocks in our large multi-hospital health care system and review associated risk factors. Methods: Using quality improvement and billing data, we established the number of wrong site blocks occurring over a 10 year period between July 1 2002 - June 30 2012 within the University of Pittsburgh Medical Center Health System (UPMCHS) under the supervision of the University of Pittsburgh Physicians Department of Anesthesiology. During the study period the number of hospitals performing blocks increased from 6 to 13. Prior to June of 2010, each hospital was responsible for verification processes surrounding interventional nerve blocks. Following the wrong site block which occurred in June 2010 a mandatory “time out policy” was developed by the Department. In March 2011, a system-wide “Prevention of Wrong Site Block” Policy was approved and introduced across all system hospitals. Results: With the exception of 1 hospital, all blocks were performed pre-operatively in a holding area. During the study period wrong site blocks were performed on 9 patients, with an overall frequency of 1 per 10,000 patients. The incidence of wrong site blocks varied from 0 to 3 per year and 0 to 3 per site. The distribution of wrong site blocks according to the time of occurrence, the hospital, the type of blocks and the relative number of blocks performed is presented in table 1. Although wrong site blocks were recorded after the development of a departmental and/or system-wide policy, in each of these cases, review confirmed that the team did not follow approved policy; In one case, the team that performed the block differed from the team performing the time out, in the second case, the time out was performed before the patient was positioned and marked, and in the most recent case the marking of the patient was not visible when the block was performed. Year Type of Block Performed A 2005 Femoral A 2006 Lumbar Plexus B 2008 Femoral C 2009 Femoral B 2010 Cervical D 2010 Interscalene* E 2011 Femoral A 2011 Lumbar Plexus C 2012 Femoral Hospital *development of a departmental system policy [Table1] Discussion: Our data suggest that risk factors for wrong site block include: 1.) the block performed most often (in our case the femoral block), 2.) the number of blocks performed at a given site, 3.) urgency for performing the block, 4.) lack of implementation of systematic prevention approach. Recent data suggest this is an endemic problem. 1 Although, in the last quarter in Pennsylvania only 4 wrong side blocks (vs 7 wrong side surgery) were reported, it is important to recognize that in terms of frequency wrong side block occur much more frequently than wrong side surgery. Data from our institution indicates that wrong side blocks are still 6 times more frequent than wrong side surgery. Conclusion: Prevention of wrong site blocks requires constant vigilance and engagement of every member of the team involved in performing a well delineated verification and prevention process. A21 ULTRASONOGRAPHIC CHARACTERIZATION OF THE PERSISTENT MEDIAN ARTERY IN PEDIATRIC PATIENTS G.R. Merritt, A. Nguyen, C. Ciarallo, D. Chatterjee, P. Carry, J. Park, F. Scott 1 2 Anesthesiology, Orthopedic Surgery, Children's Hospital Colorado, Aurora, CO, USA Introduction: During embryologic development, perfusion to the forearm and hand is provided by the 1 median artery. While most median arteries regress by 8 weeks of intrauterine life, persistent median 2 arteries (PMAs) may be detected in up to 30% of the general adult population. Antebrachial median arteries terminate in the proximal forearm and are normal, while palmar median arteries are 3 anatomical variants that terminate in the hand. PMA has been associated with carpal tunnel 4 syndrome, pronator teres and anterior interosseous syndromes. A pediatric cadaveric study described a 44% prevalence of PMAs but was limited to neonates and 5 6 infants. Recently ultrasound has been used to identify the prevalence of PMA in adults . The purpose of our study was to use ultrasonography to determine the prevalence of PMAs across a broader pediatric population and to establish the relationship between age and defined regression points. Methods: Following institutional IRB approval, patients undergoing orthopedic upper extremity surgery were enrolled in the study. Demographic data was collected (i.e. age, gender, handedness, ethnicity and race). Ultrasonographic examination was performed on both upper extremities using Logiq e ultrasound machine and a high-frequency linear transducer (GE Milwaukee, WI). Length and points of regression were documented for all PMAs. Mid P Exact tests and linear regressions were used for statistical analysis. Results: 137 limbs in 70 patients (40 male; 30 female; age range: six months to 18 years old) were evaluated. 21/70 patients demonstrated PMAs. 9/21 presented PMAs bilaterally, 7/21 presented PMAs in the right arm only, and 5/21 in the left arm only. The study cohort identified a total of 30 PMAs. The crude prevalence rate in individuals was 1 in 3 while the overall prevalence of PMAs was 2.19 per 10 limbs [95% CI: 1.51 to 3.09 per 10 limbs]. There was no difference in PMA prevalence based on gender [p = 0.4986], ethnicity [p = 0.4365] or race [p = 0.05651]. The relationship between age and the normalized percent regression point was also not statistically significant [p = 0.8455]. Discussion: The mid-forearm approach to a median nerve block has only recently been described following advances in ultrasound technology. An awareness of PMA is important during the performance of a mid-forearm block because of the risk of hematoma, compression neuropathy or intravascular injection. Based on our preliminary results, the crude prevalence of PMAs in pediatric patients is 1 in 3 individuals and 1 in 5 limbs. These numbers suggest a similar prevalence to reports in the adult population. Additionally, our preliminary data did not show age-associated regression, suggesting that post-natal regression may not be a relevant phenomenon. A22 CHANGING METHODS OF ASSESSMENT OF PEDIATRIC ANESTHESIA FELLOWS' CLINICAL UGRA PERFORMANCE BASED ON DISCORDANCE BETWEEN PRECLINICAL AND CLINICAL EVALUATIONS 1 1 1 2 D. Moore , S. Clay , L. Ding , C. Eastwood , S. Sadhasivam 1 1 Cincinnati Children's Department of Anesthesia, Cincinnati Childrens Hospital/University of 2 Cincinnati, Cincinnati, OH, Department of Anesthesiology, New Hampshire's Hospital for Children/Elliot Hospital, Manchester, NH, USA Introduction: Assessment of trainee performance can be difficult. Educators seek to establish procedural competency and safe practice benchmarks (1,2). At our institution fellows are evaluated both preclinically and clinically. Using our real-time feedback UGRA simulator and our cognitive exam, we have seen significant improvements for our fellows at 6 and 12 months of fellowship, compared to their baseline performance at the start of their fellowship (3). Concurrently, we have been assessing our fellows' clinical regional anesthesia performance. In an attempt to correlate the preclinical evaluation and the clinical evaluation, we discovered discordance between the two evaluations. Our aims of this educational research are as follows: 1. Develop an objective assessment tool for evaluation of clinical UGRA performance by pediatric anesthesia fellows. 2. Utilize UGRA simulation to assess and improve UGRA technical and cognitive skills. 3. Correlate preclinical testing and UGRA simulation with clinical performance of UGRA by pediatric anesthesia fellows. Methods: Pediatric anesthesia fellows had preclinical UGRA skill assessments at 0, 6 and 12 months with our cognitive tests and UGRA simulation models (technical accuracy and efficiency) (3). When fellows clinically performed regional anesthesia (with or without ultrasound) throughout the fellowship year, supervising faculty evaluated their technical and cognitive skills using a 1 (poor) to 5 (excellent) scoring system. Results: 10 pediatric anesthesia fellows participated in the study over 1 academic year. Preclinical cognitive and UGRA technical skills of all fellows improved at 6 and 12 months from baseline skills (Figure 1). Faculty evaluations of clinical UGRA performance of fellows in terms of mean technical and cognitive scores remained between 4 (very good) and 5 (excellent) (Figure 1). There was no statistically significant correlation between preclinical and clinical assessments. Discussion: Using our objective and standardized preclinical UGRA assessment tools, we were able to identify fellows needing additional help at the beginning of the year and demonstrate overall improvement in our fellows' cognitive and technical skills as the year progressed (3). When evaluating clinical UGRA skills, scoring of this assessment, while still in a “good” to “very good” range, decreased over time. Reasons for this included evaluators' subjective bias and temporal changes in expectations. Also, there was a relatively small sample size, which may impact the ability to draw correlations between preclinical and clinical assessments. Due to this discord between our evaluations, we have created a more objective regional anesthesia assessment tool (Figure 2) based on previous evaluation of behavior of regional anesthesia novices (4) that gives consideration to performance time and block outcome, and thus, improving our ability to objectively assess UGRA performance and competency. References: (1) Norcini et al. BMJ. 1999; 319(7218): 1183-5. (2) Norcini. BMJ 2003; 326(7392): 753-755. (3) Moore et al. Ped. Anesthesia 2012; 22(9): 847-853. (4) Sites et al. RAPM. 2007; 32(2):107-115. Funding: This project needed no additional funding. Conflicts of interest: The authors have no conflicts of interest. [Preclinical and Clinical Comparison] [Procedural Performance Sheet] A23 A SCOPING REVIEW OF THE EVIDENCE FOR TEACHING ULTRASOUND GUIDED REGIONAL ANESTHESIA (UGRA) C.M. Nix, C.B. Margarido, I.T. Awad, A. Avila, J.J. Cheung, A. Dubrowski, C.J. McCartney 1 2 Anesthesia, Sunnybrook Health Sciences Centre, Anesthesia, Sunnybrook and Women's College 3 Hospital, Obstetrical Anesthesia Research Unit, Learning Institute, SickKids, Toronto, ON, Canada Introduction: Recent Ultrasound Guided Regional Anesthesia (UGRA) education literature has called for our understanding of how anesthesia trainees develop ultrasound-guided clinical competency to 1 be based on firm scientific methodology . By advancing our knowledge of how best to teach and learn the skills associated with UGRA, we can reach a consensus on how best to structure our UGRA training programs. The purpose of this scoping review was to understand how UGRA is currently taught, as well as to investigate the scientific evidence behind UGRA education. We sought to identify key research priorities related to the future of UGRA education. Methods: Our review accounted for published articles derived from the following databases on the topic of UGRA education: US National Library of Medicine database; MEDLINE; the Excerpta Medica database; Embase; the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. We examined and summarized the extent, range and nature of the work already done in this field. Qualitative content analysis was used to identify UGRA skill components and emergent themes related to current teaching methods and future research priorities in UGRA education. Results: The search yielded 205 articles, of which 35 met the inclusion criteria and were included in the final analysis (figure 1). Three major themes emerged from the literature which reflected the different components of this complex skill: (1) The development of proficient motor skills (the trainee learning curve and assessment methods for UGRA trainees and practitioners); (2) Learning sonoanatomy (correlating 3D anatomical structures to their appearance on a 2D ultrasound image) (3) Program set up (including equipment and educational tools) and program evaluation. We also summarized the findings of recent surveys which looked specifically at UGRA education. [figure 1] Discussion: The UGRA education literature has reached a consensus on the skill components and the indications of the proficient UGRA practitioner although some of the checklists in current use for assessment need validation. An emerging evidence base supports the concept of pre-rotation learning and demonstration of the skill followed by deliberate practice of simulated UGRA blocks with supervised expert feedback. This is in order to shorten the trainee's learning curve and help them attain proficiency before they reach the clinical setting. The importance of sonoanatomy interpretation needs further evaluation as current UGRA trainees score poorly in this area. Evaluation and validation of current UGRA programs is lacking. Research into the characteristics of effective trainers and trainees has yet to happen. The concept of medical coaching is evolving but requires an evidence base. Reference: 1. Smith HM, Kopp SL, Johnson RL et al. Looking into learning: visuospatial and psychomotor predictors of ultrasound-guided procedural performance. Reg Anesth Pain Med. 2012; 37:441-447. Funding: None. No personal conflicts of interest. A24 THORACIC EPIDURAL CATHETERS IN NEONATES: PRELIMINARY RESULTS OF AN ALTERNATIVE IN-PLANE ULTRASOUND APPROACH G. Rivera, C. Larraguibel, S. Cavallieri, M. Campos, M. Caceres 1 2 Department of Anesthesiology, Hospital Luis Calvo Mackenna, Department of Anesthesiology, 3 Clinica las Condes, Department of Anesthesiology, Clinica Santa Maria, Santiago, Chile Introduction: Thoracic epidural blockade in neonates is challenging. Ultrasound guidance has been used in these blocks. Nevertheless, the out-of-plane view and the necessity of a “second hand” make this approach not so practical. Our aim was to evaluate the feasibility of the in-plane approach in a transverse view by a single operator. Material and methods: We obtained parent and/or IRB approval for the study. We recruited 32 neonates scheduled for surgeries suitable for thoracic epidural blockade under general anesthesia. We used a Sonosite M-Turbo (Bothell, WA, USA) with its high frequency linear probe (13-6 Mhz). We performed the blockades in lateral position visualizing the neuroaxis transversally. We advanced an 18G 50 mm tuohy needle, using an in-plane paramedian approach (fig-1). Once the epidural space was identified and, with confirmation of standard loss-of-resistance technique, we introduced a 20G catheter within the space (2-3 cm) (B. Braun, Melsungen, Germany). An initial bolus of 0,20% levobupivacaine 1 mL/kg was administered via catheter and 30 minutes after we started an infusion of 0,04% levobupivacaine at rate of 0,2-0,4 mg/kg/hr. We registered all data concerning demographic aspects and surgeries. During the puncture, we recorded if the dura mater and the ligamentum flavum were identified or not. The analgesia was assessed after extubation over 48 hr using the observational pain scale (OPS). The patients were rescued with 0,04% levobupivacaine 1 ml/kg via catheter if OPS ≥ 11 or, if unsuccessful, IV morphine was administered. Results: The mean of age (range) and weight (SD) was 12 (0 - 27) days and 2,74 (1,23) kg, respectively. The dura mater and the ligamentum flavum were identified in 100% and 94% of patients, respectively. In all cases, a single operator handled the probe and placed the catheter without any problem. The spaces T6-7 and T7-8 were the most frequent choice with 38% and 25%, respectively. No dural puncture or hematoma was detected clinically. Eighty-four per cent of the cases were extubated during the first 24 hr. The analgesia was considered effective in 80% of cases. Opioid rescue was needed in 20%, because in these patients catheters were accidentally dislodged and/or with an evident filtration. [Transverse US view in-plane approach] [A: T7-8 US image, B: Needle tip in epidural space] Discussion: This report shows that the ultrasound transverse view of the neuroaxis with an approach in-plane may be an alternative for neonatal thoracic epidural blocks. At this age, the sound beam penetrates easily and offers a great detail of the needle tip. Despite of the technical difficulties involved, this approach is achievable by a single operator without problem. Although, this technique may represents an attractive alternative. There are some issues concerning evidence of safety, and practical considerations in the post-operative period. Finally, if this approach is better than previous approaches, remains to be elucidated. References: - Willschke H, Marhofer P, Bösenberg A, et al. Brit J Anaesth 97(2): 200-7, 2006 - Rapp HJ, Folger A, Grau T. Anesth Analg 101: 333-9, 2005 - Willschke H, Marhofer P, Bösenberg A, et al. Brit J Anaesth 95(2): 226-30, 2005 Conflict of interest: Nothing to disclose A25 FOCUSED RISK ANALYSIS: REGRESSION MODEL BASED ON 5,314 PATIENTS UNDERGOING TOTAL JOINT REPLACEMENT SURGERY AT A SINGLE INSTITUTION S. Sinha, C. Lewis, I. Inneh, D. Smith, S. Schutzer, R. McAllister, E. Silverstein 1 2 3 Anesthesiology, Orthopedics, Connecticut Joint Replacement Institute / St. Francis Hospital and Medical Center, Hartford, CT, USA Introduction: Complications following total joint arthroplasty (TJA) surgery lead to poor functional outcomes. Identifying patients at increased risk for complications will permit risk stratification and optimization pre-operatively. The objective of this study was to identify independent pre-operative risk factors that: 1. Increase the risk of re-operation in same admission 2. Prolong length of stay (LOS) >4 days in patients undergoing TJA 3. Increase risk of re-admission within 30 days of index surgery 4. Increase risk of serious orthopedic complication 5. Increase risk of major non-orthopedic complication Methods: Data from 5314 patients undergoing primary TJA at the Connecticut Joint Replacement Institute from October 1, 2008 to September 30, 2011 were obtained from our joint registry and hospital databases. Data were collected on demographic variables, surgical information and comorbidities from the following nine (9) body systems. Logistic multivariate regression analysis (alpha < 0.05) was conducted to serve as the basis for a risk prediction tool. Based on the presence of statistically significant predictors, an equation was generated for prospective use in our center regarding the likelihood of developing complications or readmission in future patients. Results: The incidence of re-operation on same admission was 0.2%. History of UTI or urinary retention (Risk Ratio (RR)7.57;p=0.003) and blood disease(thrombocytopenia) (RR8.80;p=0.047) predicted increased risk of re-operation. Length of stay was greater than 4 days in 0.8% of patients in this cohort. Variables Risk Ratio 95% CI Operating Time (mins) 1.02 1.01 1.02 0.000 Coronary Artery Disease 3.72 1.74 7.94 0.001 Chronic Renal Failure 6.78 2.93 15.7 0.000 Blood Disease 9.4 2.08 42.5 0.004 Neoplasm 8.69 1.72 43.9 0.009 Delirium 59.0 18.4 189.7 0.000 Psychosis 28.6 2.83 2888.1 0.004 Transient Mental Disorder 50.7 4.54 567.1 0.001 [LOS>4 days] p value The re-admission rate within 30 days of index surgery was 2.8%. Variables Risk Ratio 95%CI P value Age 2.12 1.38 3.26 0.001 Procedure (TKA:THA) 0.670 0.48 0.934 0.018 Operating time(mins) 1.01 1.00 1.02 0.003 CVA/TIA 3.04 1.57 5.90 0.001 Diabetes 2.01 1.39 2.91 0.000 PE/DVT 2.19 1.20 4.00 0.10 Depressive Psychosis 14.2 1.44 140.5 0.023 [Readmit with 30 days] The risk factors predicting increased risk of orthopedic and major non-orthopedic complications are listed in the table. [Table 3] A Prediction Equation was generated: Probability of a Primary Endpoint/Complication={OR/(1+OR)}; Where OR=exp{log(p/1-p)}; Log(p/1-p) = a+bx1+bx2 + bx3..... X=predictor variable, b=beta coefficient, a=intercept/constant Discussion: This predictive tool needs to be applied prospectively to a validation cohort.Funding: No external Funding. A26 IMPACT OF AN ACUTE PAIN SERVICE ON EPIDURAL CATHETER REPLACEMENT RATES USED FOR POSTOPERATIVE ANALGESIA IN A CANCER HOSPITAL J. Su, J.M. Soliz, K.U. Popat, R. Gebhardt Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, USA Introduction: Reasons for failed epidural analgesia are multiple. Some reasons for inadequate epidural blockade include incorrect placement, epidural catheter migration, and suboptimal dosing. Definition of failed epidural analgesia varies in the literature. Reported epidural failure rates range 1 from 13% to 47.1%. In this study we define an epidural failure if the epidural catheter required replacement. In our institution specializing in cancer treatment, epidural catheters are placed by resident and faculty anesthesiologists for postoperative analgesia primarily for open thoracic and abdominal procedures. Epidural analgesia is managed postoperatively by APM (Acute Pain Medicine) service consisting of residents, acute pain nurses, and APM faculty. We reviewed the incidence, causes of epidural replacements, and describe interventions to decrease epidural replacement rates. Methods: After approval from Institutional Review Board, the number of thoracic and lumbar epidural catheters used for postoperative analgesia was obtained from our billing database from January 1, 2006 to December 31, 2011. Using our APM database, a search was performed for all epidural replacements documented from 2006 to 2011. An audit was performed documenting indications for replacement from January 1, 2007 to December 31, 2007. The number of epidurals performed with resident involvement in 2007 was obtained from our electronic anesthesia record database. Interventions included presentations on epidural management in early 2008 and 2010 along with notifications to practitioners after epidural replacements. We regressed proportion of epidural replacements and lumbar epidurals by year to obtain trend over time provided by slope of regression line. P-values corresponding to use of linear regression to test if slope of line was significantly different from zero were reported. Results: 11,769 epidural catheters were billed for postoperative analgesia from 2006 to 2011 consisting of 93.7% (n=11,026) thoracic and 6.3% (n=743) lumbar epidural catheters. Replacement rates peaked in 2007 at 7.4% (n=181). In 2007, 12.4% of all epidurals initially performed had resident participation. Of the replaced epidurals in 2007, 20% (n=36) initially involved residents, and 80% (n=145) involved faculty anesthesiologists. 86% (n=156) of replacements initially involved non-APM anesthesia personnel and 14% (n=25) involved APM personnel. Indications for replacement included 64% (n=114) with no sensory block obtainable, 16% (n=29) catheter migrated out, 15% (n=27) inadequate analgesia due to low sensory block and/or lower extremity weakness, and 5% (n=11) due to other causes. Lumbar epidural placements decreased from a peak of 12.1% in 2006 to 2.4% in 2010. A significant trend in decreasing epidural replacements of 1.1% per year (p=0.017) and lumbar epidurals of 2.0% per year (p=0.002) were found. Lowest rates of replacement, 1.9%, occurred in 2010 and 2011. [Decreasing trend 1.1% per year (p=0.017)] [Decreasing trend 2.0% per year (p=0.002)] Discussion: Significant lower incidence of epidural catheters requiring replacement was found after educational presentations and feedback. Future analysis will include current indications for epidural replacements in efforts to continue to decrease epidural failures. References: 1. Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth. 2012 Aug;109(2):144-54. Epub 2012 Jun 26. Review. A27 EPIDURAL CATHETER WITH INTEGRATED LIGHT GUIDES TO DETECT MALPOSITION: A PORCINE MODEL FEASIBILITY STUDY S.J. West, R. Del Soto, S. Putnis, J.C. Hebden, A.E. Desjardins 1 2 Anaesthetic Department, University College Hospital, London, Medical Physics and Bioengineering, 3 University College London, Orthopaedic Department, University College Hospital, London, London, UK Introduction: Epidural catheter insertion is a blind technique that involves a significant rate of malposition. For instance, in obstetric anaesthesia, the rate of initial intravascular placement is 5-7% (1). Malposition has serious consequences, which include local anaesthetic toxicity that can take place when a catheter enters a blood vessel. Aspiration of blood is unreliable and test dosing with epinephrine not recommended in parturients (1). Recent studies have demonstrated that measurements of optical reflectance can provide information relevant for tissue differentiation during needle insertions (2,3). In this study, we present a novel optical catheter with integrated light guides that allows for measurements of optical reflectance to be acquired from tissues at the distal tip. Material and methods: A custom epidural catheter with four integrated light guides was developed with a polymer extrusion process (Fig. 1). [Figure 1] Broadband visible and near-infrared light was delivered through one light guide, where it was absorbed and scattered in tissue at the distal tip of the catheter; a portion of the scattered light was collected by a second light guide and measured with a spectrometer. To determine the feasibility of optical tissue differentiation, measurements were acquired during a post-mortem laminectomy of a swine, with the catheter manually positioned on exposed tissues (Fig. 2). [Figure 2] The swine had been sacrificed as part of an unrelated ethics-approved experiment. Results: All of the spectra acquired from tissues exhibited features that were consistent with the presence of haemoglobin, which is known to be a prominent absorber of light in the wavelength range of 500 to 600 nm. Prominent differences between the spectra acquired from venous blood and all other spectra were observed. In particular, the features associated with haemoglobin absorption were more pronounced in spectra acquired from blood than those acquired from epidural fat, and the average intensity of the former spectra was lower than that of the latter by a factor of 31. Discussion: An epidural catheter has previously been considered a passive device; we have demonstrated that catheters can include active optical components that allow for tissue sensing without changes to their dimensions. The results of this study highlight the potential of optical reflectance sensing as a novel method for detecting catheter malposition, both immediately after placement and over the duration of infusion. References: 1. J. Guay. “The epidural test dose: a review”. Anesthesia & Analgesia.102(3):921-929 (2006). 2. C. Ting, M. Tsou, P. Chen, et al. “A new technique to assist epidural needle placement: Fiberoptic-guided insertion using two wavelengths,” Anesthesiology.112(5),1128-35 (2010). 3. Rathmell JP, Desjardins AE, van der Voort M, et al. “Identification of the Epidural Space with Optical Spectroscopy: An In Vivo Swine Study,” Anesthesiology. 113(6):1406-18 (2010). Funding disclosures: Equipment costs were met by a Royal Society grant. Personal conflicts of interest disclosure: Nothing to disclose A28 PARAVERTEBRAL BLOCKS FOR AMBULATORY BREAST TUMOUR RESECTION: EFFECTS OF AN INHALATIONAL GAS- AND OPIOID-FREE ANESTHETIC ON THE QUALITY OF RECOVERY. RANDOMIZED CONTROLLED TRIAL F.W. Abdallah, P.J. Morgan, T. Cil, A. McNaught, J. Escalon, J. Semple, V.W. Chan 1 2 Anesthesiology, Surgery, University of Toronto, Toronto, ON, Canada 1 Background: Current evidence associates tumor recurrence and metastasis with postoperative pain, 2-5 6-8 6, 9-11 surgical stress, inhalational anesthetics, and opioid use. Consequently, regional anesthesia 12-15 16 techniques are advocated for tumor resection surgery as they effectively treat surgical pain, 17 attenuate the neuroendocrine stress response, and minimize the use of general anesthetics and opioids. This study examines the effects of using an inhalational gas- and opioid-free anesthetic technique that relies on total intravenous anesthesia (TIVA) and thoracic paravertebral blocks (PVBs) on the quality of recovery (QoR) following ambulatory breast tumor resection. Methods: Sixty-six adult females undergoing breast tumor resection surgery were randomized to receive a standardized general anesthetic regimen inclusive of sevoflurane, fentanyl, and morphine (General Group) or a combination of PVBs and propofol-based anesthesia (PVB Group). The PVB group received 5mL of ropivacaine 0.5% in each of the T1-T5 paravertebral spaces on the operative 18 side using an out-of-plane parasagittal technique. The General group received five-level sham blocks with subcutaneous saline. QoR was assessed before discharge and on postoperative day 7 (POD) 2 using the QoR questionnaire. Secondary outcomes including pain scores on admission and discharge from post-anesthesia care unit (PACU), discharge from hospital, and POD2; intra- and postoperative opioid consumption; time to first analgesic request; incidence of nausea and vomiting (PONV); patient satisfaction; and discharge time were assessed. Results: Data from sixty-four patients was analyzed. Patient demographics were similar between groups (Table 1). The QoR score before discharge and on POD2 was superior in the PVB group; 146(143-149) and 144(141-149) versus 131(126-135); P< 0.0001 and 138(131-145); P= 0.013, respectively in the General group (Figure 1). Pain scores were also lower in the PVB group on admission and discharge from PACU, discharge from hospital, and on POD2 (Figure 2). Intraoperative morphine consumption, incidence of PONV, and discharge time were lower in the PVB group (Table 2). The groups did not differ in postoperative morphine consumption, time to first analgesic request, and patient satisfaction. Conclusion: Combining propofol-based general anesthesia and PVBs provides superior quality of recovery, analgesia, and shorter discharge time than an inhalational and opioid-based anesthesia in patients undergoing ambulatory breast tumor resection. Parameter USG-PVB (n=33) General anesthesia (n=31) P-value Age (years) 53.1 +/- 12.3 56.5 +/- 12.5 0.14 Height (cm) 164.9 +/- 7.6 161.5 +/- 6.1 0.27 Weight (kg) 68.0 +/- 9.4 67.6 +/- 12.3 0.35 BMI (kg/m2) 24.7 (22.2-28.2) 24.7 (21.0-31.7) 0.73 ASA classification (I/II) 11/22 13/18 0.48 [Patient characteristics] General anesthesia (n=31) P-value Intraoperative. morphine 1.67 +/- 3.04 consumption 15.94 +/- 7.76 <0.0001 Postoperative. morphine 10.59 +/- 13.45 consumption 14.55 +/- 14.69 0.27 Time to first analgesic request 58.22 +/- 36.52 68.57 +/- 81.01 0.59 Incidence of PONV 3/33 12/31 0.004 Time to discharge 190.19 +/- 51.58 239.87 +/- 78.35 0.005 Patient satisfaction 9.8 +/- 0.5 9.5 +/- 1.0 0.13 Outcome USG-PVB (n=33) [Results] [Figure 1] [Figure 2] A29 ULTRASOUND-GUIDED SCIATIC NERVE BLOCK FOR TOTAL KNEE ARTHROPLASTY: A COMPARISON OF THE SUBGLUTEAL SPACE AND THE INFRAGLUTEAL INJECTION TECHNIQUES. RANDOMIZED CONTROLLED TRIAL F.W. Abdallah, V.W. Chan, A. Koshkin, R. Brull Anesthesiology, University of Toronto, Toronto, ON, Canada Background: Sciatic nerve block (SNB) can provide clinically significant analgesia in total knee 1,2 3, 4, 5 arthroplasty (TKA), but it is among the least performed peripheral blocks. Challenges associated with SNB include technical difficulty, procedural discomfort, and unreliable success, 6, 7 8 particularly in obese patients. The ultrasound (US)-guided infragluteal approach to SNB can 9 reduce local anesthetic requirements compared to traditional blind techniques. However, US does 10 not overcome the challenges posed by anatomical depth. Rather than directly targeting the sciatic nerve itself, the recently described US-guided “subgluteal space” technique for SNB may hasten performance time and potentially reduce complications by injecting local anesthetic in the facsial plane between the readily-identifiable gluteus maximus and biceps femoris muscle at the level of the 11 greater trochanter and ischial tuberosity. We primarily aimed to evaluate the time to perform novel subgluteal space technique compared to infragluteal approach to SNB in TKA patients. Procedurerelated discomfort, adverse events, postoperative opioid consumption, pain scores, and side effects were also assessed. Methods: Twenty-eight patients undergoing US-SNB for unilateral TKA under spinal anesthesia and continuous femoral block were randomized to either a subgluteal space or an infragluteal techniques. We injected 30mL local anesthetic admixture (10mL lidocaine 2% mixed with 20mL bupivacaine 0.5% with 1:400,000 epinephrine) in all patients. Sensory and motor functions were assessed up to 30min by a blinded observer. The primary outcome was performance time. Results: Twenty-seven patients were analyzed. Patient characteristics were similar between groups. The block procedure time was 4.36+/-1.28 min in the subgluteal space group and 9+/-2.35 min in the infragluteal group (P< 0.00001) (Table 1). Procedural pain scores were lower in the subgluteal space group (Figure 1). The complete sensory and motor block rates in the tibial and common peroneal nerves at 30min did not differ between groups (Figure 2). There was no difference between the two groups in the procedural sedation requirements (Table 1), postoperative rest pain scores (Figure 1), time to first analgesic request, and cumulative 24h morphine consumption (Table 1). Three patients in the infragluteal group developed transient paresthesias in the tibial nerve distribution that lasted up to one week. Conclusion: The subgluteal space SNB technique is faster and less traumatic to perform, with no detectable differences in block success and cumulative 24-hr postoperative opioid consumption. Future larger studies are needed to investigate potential differences in analgesic efficacy of the two techniques. Subgluteal space Infragluteal P-value Block procedure time (min) 4.36 +/- 1.28 9 +/- 2.35 0.000007 Circumferential spread achieved 2/14 12/13 0.0009 Pain VAS score during block 1.32 +/- 1.20 2.27 +/- 1.51 0.043 Midazolam requirements 1.96 +/- 0.66 during block (mg) 2.14 +/- 0.77 0.26 Time to first analgesic request (min) 11.15 +/- 10.32 0.29 Cumulative 24 hour oral morphine equivalent 126.38 +/- 82.35 consumption (mg) 138.25 +/- 79.93 0.7 Incidence of PONV 9/14 10/13 0.48 Incidence of block complications on day 7 0/14 3/13 0.15 [Results] [Figure 1: Pain scores] 13.28 +/- 9.46 [Figure 2: Block onset] A30 COMPARATIVE EVALUATION OF STIMULATING CATHETERS TO ECHOGENIC NEEDLE AND CATHETER FOR SCIATIC BLOCK: A RANDOMIZED PROSPECTIVE STUDY J. Brookes, R. Sondekoppam Vijayashankar, S. Ganapathy, K. Armstrong, S. Dhir, M. Terlecki Anesthesiology and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada Introduction: Visibility of needle tip and catheter tip are essential to perform safe and successful peripheral nerve blocks. This can be challenging with the use of ultrasound in obese patients. Echogenic needles and catheters may facilitate positioning of the catheter tip correctly. This study comapares the safety and efficacy of the echogenic system with the traditional stimulating catheter system. Material and methods: Seventy patients scheduled for total knee joint arthroplasty willing to have a continuous femoral and sciatic blocks were randomized to receive the sciatic block either using the stimulating catheter system with the needle positioned with ultrasonography and neurostimulation or using the echogenic needle and catheter to position the catheter using only ultrasound. All blocks were done with Sonosite M Turbo machine with a curved array 3-5MHz probe with the patient in the lateral decubitus.The number of attempts, time to first twitch, time to complete insertion of catheter and number of needle and catheter redirections were recorded. Catheter tip location was also assessed using color doppler. The entire loops of ultrasound recording was given to 2 independent blinded researchers to grade the visibility of the needle and the catheter tip on a categorical scale of 1-3, 3 being the best view.The sensory motor block was evaluated every 5 mins for the next 30 minutes. Results: The demographics were similar between the groups.(Table 1) The visibility of the needle and the catheter were better with the echogenic system but the onset and completeness of the block was better with the stimulating catheter.There was no difference in the time required to insert the catheters in the acceptable location. The number of needle redirections and catheter reinsertions were lower in the echogenic group. Discussion: This is a preliminary report of a total of 44 patients out of the 70 randomised and we will present the final data at the meeting.The echogenic system allows fewer passes of the needle and fewer redirection of the needle. The onset of block is much faster with the stimulating technique. References: 1. Needle visualization in ultrasound-guided regional anesthesia: challenges and solutions Chin, KJ, Perlas A, Chan, VWS, Brull, R. Regional anesthesia and pain medicine 2008;33:532-544 2. Investigation of a new echogenic needle for use with ultrasound peripheral nerve blocks. Deam RK, Kluger R, Barrington MJ, McCutcheon CA. Anaesth Intensive Care. 2007 Aug;35(4):582-6. Variable Stimulating N=26 Echogenic n=18 P value Age in yrs(SD) 65.03 (10.3) 66.1 (11.4) 0.7 Male/Female 12/14 7/11 0.6 Weight in KG (SD) 87.3 (15.2) 89.2 (22.4) 0.7 Height in cm(SD 165.4 (9.1) 166.4(10.7) 0.7 BMI (SD) 31.8(4.7) 31.6(5.8) 0.9 Time to first twitch sec(SD) 163.9(126.7) 150.1(162) 0.75 Cath ins end sec(SD) 424.9(234) 346.9(183) 0.2 No. of Needle redirection (SD) 2.03(1.8) 0.78(0.9) 0.01* No. cath redirection (SD) 0.46(0.8) 0.056(0.24) 0.046* [Demographics] [Block Progress compare] A31 OPTIMAL PLACEMENT OF INTRA-ARTICULAR CATHETERS FOR DIFFUSION OF ANALGESIC IN TOTAL KNEE ARTHROPLASTY C. Press, G. Votta-Velis, K. Chakour, A. Borgeat, M. Gonzalez 1 2 3 Orthopaedics, Anesthesia, University of Illinois at Chicago, General Surgery, University of Chicago, Chicago, IL, USA When placing an intra-articular pain catheter within the knee for post operative analgesia, we recommend placement within the supra-patellar space to achieve superior diffusion within the joint. Background: Continuous Wound Infusion (CWI) techniques have been used in Total Knee Arthroplasty to decrease post operative pain. Previous studies using CWI catheters utilize a wide variety of approaches for catheter placements which may have important implications in the overall diffusion of the administered local anesthetic. In our review of the literature, there is no study that provides guidance to optimal catheter position. The purpose of this study was to determine the position of the catheter which provided the maximum amount of volume dispersion within a total knee arthroplasty. Methods: Six cadaveric knees underwent total knee arthroplasties using standard techniques with catheters placed in one of three locations: Supra-patellar, Medial Gutter, Lateral Gutter. The catheters were infused with radio-opaque dye and placed on a continuous passive motion (CPM) machine for one hour. Fluoroscopic images were obtained at regular time intervals (0, 1, 5, 60 mins) to identify diffusion patterns within the joint. Areas of the knee were considered infiltrated when dye was visible at pre-determined anatomic landmarks. Results: Superior global diffusion rates were achieved with the catheter placed in the supra-patellar pouch over both the medial or lateral gutters. Posterior capsular diffusion (as detected by dye visible superior to the femoral condyles) was achieved in all catheter positions and found to be similar. Anterior capsular diffusion (detected by dye penetrance at the inferior pole of the patella) was found only to take place in the supra-patellar position. Conclusion: When placing an intra-articular pain catheter within the knee, the supra-patellar space achieved superior diffusion within the joint compared to both the medial and lateral gutters. This anatomic position may also confer additional benefits to early rehabilitation by limiting the risk of entrapment of the catheter within the femoral and tibial component during early range-of-motion exercises. By defining a catheter placement technique, we hope to impart greater efficacy to these devices and help standardize a location for optimal pain control. A32 CHOICE OF ANESTHESIA TYPE AND PERIOPERATIVE OUTCOMES IN PATIENTS WITH SLEEP APNEA UNDERGOING TOTAL JOINT ARTHROPLASTY: A POPULATION-BASED STUDY 1,2 1,2 1 1 1 1 1 T. Danninger , O. Stundner , R. Rasul , X. Sun , Y.-L. Chiu , P. Fleischut , M. Mazumdar , S.G. 1 Memtsoudis 1 Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell 2 University, New York, NY, USA, Department of Anesthesiology, Perioperative Medicine and Intensive 3 Care Medicine, Paracelsus Medical University, Salzburg, Austria, Division of Biostatistics and 4 Epidemiology, Department of Public Health, Weill Medical College of Cornell University, Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY, USA Introduction: The presence of SA among surgical patients has been associated with significantly increased risk of perioperative complications [1]. Although regional anesthesia has been suggested as a means to reduce complication rates among SA patients undergoing surgery [2], no data are currently available to support this approach. Material and methods: We analyzed data from 400 US hospitals. Patients who underwent primary hip or knee arthroplasty with a concomitant diagnosis of sleep apnea between 2006 and 2010 were identified. Perioperative outcomes were compared between patients undergoing surgery under general, neuraxial, and combined neuraxial-general anesthesia. The independent impact of the anesthesia technique on outcomes was assessed. Results: We identified 44,086 entries for patients with a diagnosis for SA undergoing primary hip or knee arthroplasty. 32,641 (74%) had information about anesthesia type available. Approximately 10% of cases were performed under neuraxial, 14% under combined neuraxial and general and 76% under general anesthesia. Patients undergoing their procedure under neuraxial anesthesia had significantly lower rates of major complications compared to those undergoing surgery under combined neuraxial/general or general anesthesia (16.0%, 17.0% and 17.9%, P=0.0262). Rates of pulmonary, gastrointestinal and infectious complications as well as acute renal failure in particular were higher in those undergoing surgery involving a general anesthetic compared to a neuraxial approach. Utilization of transfusions, mechanical ventilation and critical care services were significantly lower in the neuraxial and combined neuraxial and general groups than in the general anesthesia group. When controlling for covariates, the odds for combined major complications were lower among patients receiving neuraxial anesthesia compared to general anesthesia (Odds Ratio (OR)=0.89, 95% CI 0.81-0.98,p=0.02; OR=0.84, 95% CI 0.75-0.74, p=0.002). Discussion: Barring contraindications, neuraxial anesthesia should be considered as the anesthetic of choice in patients with SA undergoing joint arthroplasty. Further research is needed into the mechanisms by which neuraxial anesthesia confers beneficial effects compared to the general approach. References: 1. Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest 2012;141:436-441. 2. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006;104:1081-93 A33 TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK IN RENAL ALLOTRANSPLANT RECIPIENTS: A RETROSPECTIVE CHART REVIEW L. Bejar, S. Gopwani, M. Rosenblatt Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA Introduction: A TAP block targets the ventral rami of T7-L1, which carry somatic sensory nerves to the anterior abdominal wall. While some studies have shown significant opiate-sparing effects of the 1 2 TAP block , this finding has not been consistent across all intra-abdominal procedures . A 2010 study of 20 patients found TAP blocks resulted in significant decreases in morphine 3 consumption during the first 24 hours following renal allotransplant . This was controverted in 2012, in a randomized controlled trial of 65 patients showing no difference in morphine consumption at any 4 time point after surgery . TAP blocks in the latter study were performed without ultrasound guidance. Materials and methods: IRB approval was obtained. The anesthesia information management system, CompuRecord (Philips Medical, Andover, MA), was queried for all renal allotransplants from May 1, 2011 through September 15, 2011. Data extracted included details of block placement, intraoperative narcotic administration, and post-operative narcotic consumption over the subsequent 48 hours. TAP blocks were performed under direct visualization with an M-Turbo ultrasound machine (Sonosite Inc., Bothell, WA) using an L25x/13-6MHz broadband linear array probe. A 22-gauge 50mm block needle placement was inserted in an in-plane medial to lateral approach. Results: Our query resulted in 50 renal allotransplant patients. 13 patients received TAP blocks, 8 pre-incision and 5 post-operatively. 37 patients received no block. All blocks were ultrasound guided in the manner described, with an injection of 20ml of 0.25% bupivicaine. Data analysis was with unpaired t-tests. Baseline characteristics did not differ significantly. Block (n=13) No Block (n=37) p-value Age 47.57 53.73 0.1968 Weight (kg) 75.85 78.505 0.6647 Duration of Surgery (min) 227 196.65 0.0993 Intraoperative Fentanyl (mcg) 405.36 447.97 0.3968 Intraoperative Fentanyl (mcg/kg) 5.3307 5.7192 0.4069 [Baseline Patient Charecteristics] A statistically significant difference in post-operative narcotic consumption was found at all time points post-operatively. [Figure 1: Cumulative Narcotic Administration] Discussion: Considering its retroperitoneal position and complete visceral denervation, renal allotransplantation provides the most unambiguous opportunity to assess the TAP block. This review shows significant reductions in morphine equivalent consumption over multiple time points, confirming the findings of Mukhtar, et al., and disputing those more recently published by Fried, et al. Ultrasound guidance is likely an integral component of TAP block efficacy. A double-blinded randomized controlled trial assessing ultrasound guided TAP blocks for renal allotransplants has been undertaken by this group. References: 1. "Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy." Hosgood, et al. Transplantation. 2012 Sep15;94(5):520-5 2. "Transversus abdominis plane block does not provide additional benefit to multimodal analgesia in gynecological cancer surgery." Griffiths, et al. AnesthAnalg. 2010 Sep;111(3):797-801 3. "Transversus abdominis plane block for renal transplant recipients." Mukhtar, et al. BrJAnaesth. 2010 May;104(5):663-4 4. "Transversus abdominis plane block for analgesia in renal transplantation: a randomized controlled trial." Freir, et al. AnesthAnalg. 2012 Oct;115(4):953-7 Funding: None Personal conflicts of interest disclosure: Nothing to disclose A34 SUCCESSFUL FEMORAL NERVE BLOCKADE IN OBESE AND NON-OBESE PATIENTS USING A MODIFIED “2-IN-1” TECHNIQUE M. Hogan, T.J. Ozelsel, B.C.H. Tsui, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Femoral nerve blocks provide excellent lumbar plexus anesthesia; however, the 1 optimal approach remains debatable. Some groups claim that the traditional, 3-in-1 approach can 2 block the femoral, lateral femoral cutaneous, and obturator nerves consistently, while others claim 3 that the obturator nerve cannot be blocked using this method. The objective of this study was to assess the clinical efficiency of a modified, “2-in-1” technique and to investigate the effect of body mass index (BMI) on block procedure time and sensory and motor block onset times. Material and methods: After institutional ethics approval, patients scheduled for femur surgery were recruited to receive a “2-in-1” femoral nerve block for post-operative pain management prior to a general anesthetic for surgery. Under ultrasound and using the femoral artery as a landmark, the needle was advanced in-plane through the fascia lata and the fascia iliaca lateral to the femoral nerve (Figure). [Figure] A test dose of dextrose 5% in water was injected to confirm needle tip position, and 20 mL of a local anesthetic mixture (ropivacaine 0.5% + bupivacaine 0.125%) was injected. The needle was then withdrawn to a position between the fascia lata and the fascia iliaca, and another 20 mL of the local anesthetic mixture was injected. Patient weight and height were recorded, and procedural time, time to first onset of sensory blockade, and first onset of motor blockade were compared between obese 2 2 (BMI >30 kg/m ) and non-obese (BMI < 30 kg/m ) patients. Results: Fifty-two patients were recruited, and 16 (30.8%) were classified as obese. The mean BMI of obese patients was 35.8 ± 6.0 versus 24.3 ± 4.2 for non-obese patients. One obese patient required a supplementary regional block, yielding a success rate of 98% in this group; we achieved 100% success for the non-obese group. The onset of both sensory (10.7 ± 6.2 min non-obese vs. 16.3 ± 6.7 min obese; p=0.003) and motor (18.6 ± 6.1 min non-obese vs. 22.5 ± 3.9 min obese; p=0.028) block was significantly longer for obese patients. The block procedure time was also significantly longer for the obese group (208.1 ± 15.7 sec vs. 182.6 ± 24.4 sec; p=0.001) Discussion: Our results demonstrate that the modified “2-in-1” femoral nerve block technique provides effective sensory and motor block for femur surgery, regardless of BMI. Although we achieved high success in both obese and non-obese patients, both block onset time and block procedure time was significantly longer in the former group. References: 1. Winnie AP, et al. Anesth. Analg. 1973; 52: 989-96 2. Marhofer P, et al. Anesth. Analg. 1997; 85: 854-7 3. Parkinson SK, et al. Anesth. Analg. 1989; 68: 243-8 Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest: Nothing to disclose. Figure: Ultrasound-guided femoral nerve block. Fascia lata and fascia iliaca are delineated. Needle trajectory is indicated by the dashed line; green X's mark the injection points. FA, femoral artery; FN, femoral nerve. A35 INTERSCALENE NERVE BLOCK IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA UNDERGOING AMBULATORY SHOULDER ARTHROSCOPY D. Jackson, S. Orebaugh, M. Kentor, K. King, B. Williams 1 Department of Anesthesiology, Division of Acute Interventional Perioperative Pain Service, University 2 3 4 of Pittsburgh, UPMC Southside/Mercy Ambulatory Surgical Center, UPMC Passavant, Department 5 of Anesthesiology, University of Pittsburgh, Veterans Affairs Medical Center, Pittsburgh, PA, USA Introduction: As shoulder arthroscopy has become a common ambulatory procedure, interscalene 1 block (ISB) has become an increasingly favored choice as its primary anesthetic. The ipsilateral phrenic nerve palsy that often results from ISB may be particularly problematic in patients with preexisting pulmonary disease, including obstructive sleep apnea (OSA). We sought to evaluate the effects of an intermediate-duration mixture of local anesthetics in patients with OSA presenting for ambulatory shoulder arthroscopy, with particular emphasis on pulmonary symptomatology and oxygen saturation. Materials and methods: This is a prospective, observational, multi-center study of patients undergoing ambulatory shoulder arthroscopy who have known or suspected OSA based on prior 2 positive sleep study or high clinical suspicion according to ASA Practice Guidelines. ISB is performed per our standard ultrasound-guided technique using 20 ml of a mixture of 1.6% mepivicaine and 0.2% ropivicaine which we typically utilize for these patients. Patients then receive moderate sedation with propofol and ketamine for the operative procedure. The patients are evaluated postoperatively in Phase 1 and 2 recovery, as well as after discharge to assess block success, duration, and incidence of adverse events. We also compared outcome variables for those with BMI above and below 35. Results: Twenty-two patients have been enrolled. Block success has been 100%; no cases have required conversion to general anesthesia. Mean (SD) block duration, defined as time until first pain, is 10 hours and 52 minutes (6 hours and 10 minutes). No episodes of postoperative airway obstruction or desaturation have occurred in Phase 1 or Phase 2 recovery. The mean SpO2 in Phase 2 recovery in the BMI < = 35 group was 97.2%, significantly higher than the mean value of 95.2% in the BMI > 35 group (mean difference 2.00; 95% CI [0.33 - 3.67], P=0.02). There was no difference in baseline mean SpO2 values between the groups (P=0.16). All patients were discharged home where 24% noted dyspnea, though all of these patients rated it as mild and not affecting their activities. No patients required re-admission or emergency department visits for dyspnea. Discussion: We have found that intermediate-duration ISB is a safe and effective means of providing surgical anesthesia and postoperative analgesia in patients with OSA undergoing shoulder arthroscopy in an ambulatory setting. Despite the block´s tendency to cause paralysis of the ipsilateral hemidiaphragm, which may be more problematic in this patient population with preexisting respiratory impairment, no adverse events have occurred. The formulation of local anesthetics utilized in these patients is intended to limit block duration to the day of surgery, thereby avoiding the likelihood of respiratory complications that may result from OSA along with a paretic diaphragm after patients retire, while still providing a reasonable duration of analgesia. References: 1. Memtsoudis SG, Kuo C, Ma Y, et al. Changes in Anesthesia-Related Factors in Ambulatory Knee and Shoulder Surgery. Reg Anesth Pain Med. 2011;36:327-31. 2. ASA Task Force on Perioperative Management of Patients with OSA. Practice Guidelines for the Perioperative Management of Patients with OSA. Anesthesiology. 2006;104:1081-93. Funding: none Conflicts of Interest: none A36 ADDITION OF PERIPHERAL NERVE BLOCKADE TO GENERAL ANESTHESIA FOR TOTAL SHOULDER ARTHROPLASTY - DO PERIOPERATIVE OUTCOMES DIFFER? 1 1,2 1,2 1 1 1 1 I. Kao , T. Danninger , O. Stundner , R. Rasul , Y.-L. Chiu , X. Sun , P. Fleischut , C.M. 3 1 1 Brummett , M. Mazumdar , S.G. Memtsoudis 1 Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell 2 University, New York, NY, USA, Department of Anesthesiology, Perioperative Medicine and Intensive 3 Care Medicine, Paracelsus Medical University, Salzburg, Austria, Division of Biostatistics and 4 Epidemiology, Department of Public Health, Weill Medical College of Cornell University, Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, New 5 York, NY, Department of Anesthesiology, Division of Pain Medicine, University of Michigan Health System, Ann Arbor, MI, USA Introduction: Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty [1]. It remains largely unknown however, if the use of peripheral nerve blocks can affect the rate and risk of systemic complications after surgery. Therefore, we chose a population-based approach to examine the differential impact of general anesthesia with or without addition of a peripheral nerve block in patients undergoing total shoulder arthroplasty. Material and methods: In a discharge database containing data from approximately 400 US hospitals (Premier Inc), we queried for all patients who underwent total shoulder arthroplasty under general anesthesia between 2006 and 2010. Groups were established based on whether patients received a peripheral nerve block in addition to general anesthesia, or general anesthesia only. Groups were compared with regard to demographics, comorbidities and incidence of major perioperative complications. Moreover, we performed a multivariate regression analysis in order to assess the independent influence the addition of a nerve block to general anesthesia blocks exerts. Results: We identified 17,157 patients that underwent total shoulder arthroplasty between 2006 and 2010. 19.3% received an upper extremity peripheral nerve block in addition to general anesthesia. Patients receiving regional anesthesia were on average slightly younger (68.8 vs 69.4 years, P< 0.001), but had a similar comorbidity index (average Deyo index 0.91 vs 0.92, p< 0.001) and comparable prevalence of individual comorbidities, compared to those patients that received general anesthesia only. There was no relevant difference in the incidence of perioperative respiratory, cardiac or other complications between the groups. In the multivariate regression analysis, the use of general anesthesia with a peripheral nerve block versus general anesthesia only (referent) was not associated with altered odds ratios (ORs) for: combined complications OR=1.06 (CI 0.93;1.21), P=0.4053; cardiac complications OR=1.10 (CI 0.94;1.29), P=0.2441; respiratory complications OR=0.96 (CI 0.70; 1.32), P=0.814; invasive ventilation OR=0.55 (CI 0.28;1.09), P=0.0855; transfusion OR=0.93 (CI 0.78;1.12), P=0.4442; ICU admission OR=1.14 (CI 0.89;1.47), P=0.2988. However, regional anesthesia was independently associated with a lower OR for length of hospital stay th exceeding the 75 percentile, compared to general anesthesia only (OR=0.87 (CI 0.79;0.96), P=0.004). Discussion: In this large cohort of patients receiving total shoulder arthroplasty, addition of an upper extremity peripheral nerve block to general anesthesia was not associated with increased rates of or odds for perioperative complications, postoperative mechanical ventilation, transfusion, or ICU admission. However, patients receiving regional anesthesia were less likely to have increased length of stay. References: 1. Ilfeld BM et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006 Nov;105(5):999-1007. A37 PATIENT INVOLVEMENT IN SURGICAL SAFETY: A SURVEY OF PATIENT PERCEPTIONS AND SATISFACTION DURING PRE-PROCEDURAL TIME-OUT PRIOR TO PERIPHERAL NERVE BLOCKADE Y. Lai, M.R. Anderson, H.M. Lin, A. Weinberg, M.A. Rosenblatt Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA Background: Regional anesthetic procedures performed at the wrong site or on the wrong side can be catastrophic for the patient, perioperative personnel, and the institution. Numerous organizations proposed that having patients actively participate in the time-out process could be beneficial in improving communication, however, the nature and extent of this participation or its impact on preventing errors has not been determined. Moreover, there is no evidence showing how the universal protocol influences patients' perception of their surgical and anesthetic experience. A root cause analysis of wrong-site pain management injections suggests that lucid patients should not be relied on as safeguards. Hence, we need to understand whether a patient-centered verification process for peripheral nerve blockade is associated with enhanced perceptions of perioperative safety and satisfaction. Objectives: To survey patients on perceptions regarding their participation in a standardized time-out process prior to receiving sedation for regional anesthesia. Methods: After IRB approval, 189 orthopedic patients undergoing peripheral nerve blockade were recruited over a 2-month period, and they participated in a standardized nerve block verification process after baseline demographic information was collected. The regional anesthesia time-out protocol involved a written script dictating verbal participation and confirmation between the nonpremedicated patient and anesthesiologists, which was witnessed by an independent healthcare provider who is not involved in the care of the patient. A 10-item survey, with an additional narrative question, using the symmetric six point Likert scale, was modified from the Iowa Satisfaction with Anesthesia Scale (ISAS). A single investigator who was blinded to pre-procedural time out process administered the questionaire postoperatively. Results: Complete data were present for 175 patients who underwent blocks (55 interscalene, 62 supraclavicular, 5 infraclavicular, 22 femoral, 26 popliteal blocks, and 5 ankle). Survey items on perception of confidence in their nerve block, sense of safety, and participant's level of relaxation during time-out were grouped as primary composite outcomes. On a Likert scale ranging from -3 to +3, 90% of patients reported scores of +3 for all primary composite outcomes. In addition, Pearson correlation tests revealed that primary composite scores are associated with pre-procedural pain scores and overall satisfaction perioperatively. No correlation exists between primary composite outcomes and age, ASA status, and procedure type. On another survey item, 97% of patients expressed that they would not alter their involvements in the time out protocol. Lastly, 93% of participants reported high satisfaction associated with their anesthesia experience. . The survey was tested for reproducibility resulting in an 88% correlation over a 2-week period. Discussion: This study demonstrates enhanced perceptions of confidence in anesthesia providers and overall safety regarding their anesthetic care when lucid patients are allowed to participate in the pre-procedural time out process. In addition, there is no evidence to suggest that this verification process increases patient anxiety. Further studies will be needed to assess the actual impact this intervention has on preventing wrong side anesthetic blocks or surgery. References: Cohen, SP, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010.Mar;112(3):711-8. Funding: Institutional. A38 THE IMPACT OF NEURAXIAL ANESTHESIA ON DISTAL AND PROXIMAL TISSUE PERFUSION A PILOT STUDY 1 1,2 1,2 1 1 1 1 1 S.G. Memtsoudis , O. Stundner , T. Danninger , Y. Ma , J. Bae , D. Yoo , I. Kao , D. Maalouf , A. 1 1 3 3 Gonzalez Della Valle , T.P. Sculco , S.O. Heard , J.M. Walz 1 Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell 2 University, New York, NY, USA, Department of Anesthesiology, Perioperative Medicine and Intensive 3 Care Medicine, Paracelsus Medical University, Salzburg, Austria, Division of Biostatistics and 4 Epidemiology, Department of Public Health, Weill Medical College of Cornell University, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New 5 York, NY, Department of Anesthesiology, University of Massachusetts Medical School, Worcester, MA, USA Introduction: Hypotensive epidural anesthesia (HEA) has proven effective in reducing blood loss and can serve as part of a multimodal approach for prophylaxis of thromboembolism in patients undergoing total hip arthroplasty (THA) [1]. However, little data exists to detail the effect of this technique on differential perfusion changes above and below the level of neuraxial blockade. This study was designed to elucidate changes in this parameter in a clinical setting, using non-invasive near-infrared spectroscopy (NIRS) [2, 3]. Material and methods: Patients aged 18 to 85 undergoing primary total hip arthroplasty under HEA (as per institutional protocol [4]) were enrolled. Data on patient demographics (age, gender, ethnicity, comorbidities) and intraoperative data (fluid balance, duration of surgery) were recorded. Muscle oxygenation was measured by continuous sampling of NIRS spectra at two standardized locations above and below the level of neuraxial blockade (deltoid and quadriceps femoris muscles) using two CareGuide™ NIRS devices (Reflectance Medical, Westborough, MA). Stroke volume (SV) and cardiac output (CO) were recorded continuously using a validated non-invasive bioreactance monitor (NICOM™; Cheetah Medical, Vancouver, WA). Other continuously recorded parameters included heart rate (HR), invasive mean arterial blood pressure (MAP) and arterial oxygen saturation. Recordings of muscle oxygenation were compared over time and correlated with other cardiovascular parameters, separately for upper and lower extremity. For the longitudinal analysis the generalized estimating equations (GEE) method was used, controlling for age, body mass index and gender. Results: 10 patients undergoing THA under HEA were enrolled (mean age 60.3 years (SD 9.9), 2 mean BMI 26.2 kg/m (SD 5.4); mean surgical time 83.0min (SD 19.7)). Figure 1 displays mean oxygenation levels of the deltoid (blue line) and quadriceps (red line) muscles, representing perfusion status above and below the neuraxial block, respectively. While oxygenation in the deltoid muscle did not change significantly between the individual time points, longitudinal analysis of oxygenation levels in the quadriceps revealed a intermittent decline and significant difference between and across all time points (p< 0.0001). Figure 2 displays other hemodynamic parameters. While MAP reveals a decrease characteristic for hypotensive epidural anesthesia (pre-surgical baseline: 65.5mmHg (SD 24.5), nadir: 56.6mmHg (SD 11.9), surgery end: 66.1mmHg (SD 22.9)), HR and CO increased significantly over time (HR: 66 vs 74 bpm, p< 0.0001; CO: 3.5 vs 4.0 L/min; p< 0.0001). [Figure 1 - Muscle Oxygenation (SmO2)] [Figure 2 - Hemodynamic Parameters] Discussion: These preliminary results indicate that muscle oxygenation, a surrogate parameter for tissue perfusion, is significantly altered by HEA, but only within the functional limits of neuraxial blockade. Despite low systemic blood pressure, oxygenation remained unchanged in the upper extremity. In a next step, we plan to analyze relationships between other cardiovascular parameters and muscle oxygenation. A control group consisting of patients undergoing normotensive epidural anesthesia will be added. References: 1) González Della Valle A et al. Clin Orthop Relat Res. 2006 2) Treschan et al. Anesth Analg. 2003 3) Soller et al. J Appl Physiol. 2008 4) Sharrock NE et al. Acta Orthop Scand. 1996 A39 SENSORY AND MOTOR EFFECTS OF MID-THIGH ADDUCTOR CANAL BLOCK H. Murgatroyd, P. Cholvisudhi, V. Chan, A. Perlas, K. Arkadiy, K.J. Chin Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada Introduction: The sub-sartorial adductor canal block is an alternative analgesic technique to femoral nerve block in major knee surgery. A potential advantage is sparing of quadriceps weakness, allowing earlier patient mobilization. [1, 2] However, the dose of local anesthetic required for optimum analgesia has not been determined. This prospective pilot study aimed to determine the extent of sensory and motor effects of adductor canal blockade performed with 20 ml of Ropivacaine 0.5% with 1:400,000 epinephrine. Materials and methods: Following Research Ethics Board approval, nine patients undergoing elective total knee arthroplasty received a mid-thigh ultrasound-guided adductor canal block. Sensory blockade was measured by tolerance to increasing current of Transcutaneous Electrical Stimulation (TES) in four quadrants surrounding the patella, up to a maximum tetanic stimulus of 60 mA at 50 Hz for 5 seconds (considered equivalent to surgical anesthesia [3]). Pinprick sensation mapping was performed 30 minutes after block completion. Motor blockade of the quadriceps was measured by isometric force dynamometer every 10 minutes for up to 40 minutes following the block. Results: Surface analgesia to pinprick sensation: Data was available for 8 out of 9 patients. A consistent area of analgesia covering all four quadrants of the anterior aspect of the knee from above the patella to the tibial tuberosity was obtained in all eight patients (Figure 1). Surface analgesia extended distal to the tibial tuberosity in 4 patients. [Figure 1: Loss of pinprick sensation.] Transcutaneous Electrical Stimulation: There was a trend towards an increase in tolerance to 1 Hz TES over time. (Figure 2) Four out of nine patients developed tolerance to 50 Hz TES, but no patient was able to tolerate TES equivalent to surgical stimulus. [Figure 2: Tolerance to TES] Quadriceps strength: There was no reduction in quadriceps strength at 20 minutes following the block. There was, in fact, a non-significant increase in median quadriceps strength from 20 (IQR: 19 - 23) to 22 (IQR: 15-25) pounds of force. Discussion: Adductor canal blockade with 20 ml of 0.5% Ropivacaine appears to consistently produce surface analgesia over all four anterior quadrants of the knee, whilst preserving quadriceps motor power. No patients were able to tolerate 60 mA of tetanic stimulation for 5 seconds [3], which suggests that this dose does not produce surgical anesthesia. References: 1. Lund J, et al. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55(1): 14-9. 2. Manickam B, et al. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 2009; 34(6): 578-80. 3. Chiu AA, et al. The effects of epinephrine on lidocaine spinal anesthesia: a cross-over study. Anesth Analg 1995; 80(4): 735-9. Funding disclosure:Study was funded from the departmental budget. Personal conflicts of interest disclosure:Nothing to disclose A40 REPRODUCIBILITY OF SENSORY THRESHOLD CURRENT FOR THE NEUROMETER AND A PERIPHERAL NERVE STIMULATOR IN HEALTHY VOLUNTEERS T.J. Shakespeare, B.C.H. Tsui, D.H. Leung, J.H. Tsui, G.N. Corry, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Current methods of assessing nerve blocks, such as loss of perception to cold sensation, are subjective at best. Transcutaneous nerve stimulation has previously been used to 1-3 measure current perception threshold (CPT) in individuals with neuropathic conditions. Various 2;4 commercially available devices, such as the Neurometer, allow one to measure CPT and may be useful as a tool for assessing peripheral nerve blocks. Here, we have tested the ability of the Neurometer and a common peripheral nerve stimulator to provide reproducible CPT readings on healthy volunteers. Material and methods: We recruited ten volunteers to examine CPT reproducibility using the Neurometer (Neurotron, Inc., Baltimore, MD, USA) and the StimPod NMS450 peripheral nerve stimulator (Xavant Technology, Pretoria, South Africa) (Figure 1). [Figure 1] Subjects' CPT was determined for the median (second digit) and ulnar (fifth digit) nerve sensory distributions of both hands at 5 Hz, 250 Hz, and 2000 Hz with the Neurometer and at pulse widths of 0.1 ms, 0.3 ms, 0.5 ms, and 1.0 ms, both at 5 Hz and 2 Hz, using the StimPod. Intraclass correlation coefficients (ICC) were calculated to assess reproducibility; ICC values < 0.4 are considered poor, 5 values between 0.4 and 0.75 are considered good, and values ≥ 0.75 are excellent. Results: Six male and four female volunteers were recruited for the study; no subjects withdrew due to test discomfort. During the study, sensory perception with the Neurometer was reported by most volunteers as “tingling,” while the StimPod stimulus was reported as “tapping.” All of the ICC values fell within the good and excellent ranges for reproducibility except those of the Neurometer at 5 Hz (second digit, 0.292; fifth digit, 0.318) (Figure 2). [Figure 2] Discussion: The StimPod peripheral nerve stimulator displayed acceptable reproducibility in measuring CPT in healthy volunteers, whereas at a similar low frequency, the Neurometer's reproducibility fell outside the acceptable limit. These results suggest that peripheral nerve stimulators may be useful devices for measuring CPT to assess nerve blocks. References: 1. Katims et al. J.Occup.Med. 1986; 28: 1219-21 2. Masson EA et al. Diabetologia 1989; 32: 724-8 3. Matsumoto R et al. J.Int.Med.Res. 2005; 33: 442-53 4. Masson EA et al. Diabet.Med. 1991; 8: S63-S66 5. The design and analysis of clinical experiments. New York, Wiley, 1986. Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Partial funding for this study was provided by from the Department of Anesthesiology and Pain Medicine. Personal conflicts of interest: Nothing to disclose. Figure 1. Setup of current perception threshold testing equipment. Shown are the Neurometer, StimPod NMS450, switch box, and subject with stimulating and ground electrodes attached. Figure 2. Reproducibility of the Neurometer and StimPod at each setting for the second digit (A) and fifth digit (B). Reproducibility is represented by ICC (filled circles); bars indicate 95% confidence intervals. A41 HANDS-ON GEL PHANTOM AND INSTRUCTIONAL VIDEO TRAINING IMPROVE SONOANATOMY KNOWLEDGE: A RANDOMIZED CONTROLLED TRIAL 1 1 1 2 B.A. VanderWielen , R. Harris , R.E. Galgon , L.M. VanderWielen , K.M. Schroeder 1 1 2 University of Wisconsin, Department of Anesthesiology, University of Wisconsin, Madison, WI, Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA 3 Introduction: Millions of patients worldwide annually receive neuraxial anesthesia. Obesity, pregnancy, and abnormal spinal anatomy pose challenges for accurate landmark palpation. 1,2 Ultrasound can be utilized to identify relevant structures and decrease procedural complications. 3 Gel phantom models and instructional videos are low-cost ultrasound teaching tools, but literature on their effectiveness remains limited. This study evaluated hands-on gel phantom and instructional video training for teaching spinal sonoanatomy amongst anesthesiology faculty and residents. Materials and methods: Following IRB approval, 23 residents and 27 anesthesiologists, randomized to gel phantom, video teaching, and control groups participated. Gel Phantom Video Training Control Overall Residents Faculty Overall Residents Faculty Overall Residents Faculty (n=17) (n=8) (n=9) (n=18) (n=8) (n=10) (n=15) (n=7) (n=8) 38.47 (12.59) 28.50 (1.51) 47.33 37.00 (10.34) (7.55) 30.88 (1.89) 41.90 (6.71) 43.73 (13.81) 31.86 (4.49) 54.13 (9.98) Anesthesiology 9.47 Experience, yrs (Mean, (10.96) SD) 1.75 (0.89) 16.33 7.44 (11.27) (7.41) 2.00 (0.76) 11.80 (7.48) 15.07 (14.65) 2.57 (0.53) 26.00 (11.66) Spine Anatomy Analysis Experience (%) 17.6 25 11.1 11.1 12.5 10 0 0 0 Epidrual/Spinal/Lumbar Puncture Experience 17.6 (%) 25 11.1 5.5 12.5 0 0 0 0 Peripheral Nerve Blockade Experience (%) 64.7 50 77.8 50 75 30 73.3 100 50 Vascular Access Experience (%) 100 100 100 100 100 100 80 100 62.5 Age, yrs (Mean, SD) [Group Demographics] A lumbar spine gel phantom model and an instructional video were created and used to teach sonoanatomy (lamina and spinous and transverse process) identification. [Spine sonoanatomy] All participants attempted ultrasound identification of these structures on a human volunteer, both immediately and three weeks later. Perceived knowledge and training modality satisfaction (intervention groups) were assessed using modified Likert scales. Results: Both interventions improved spine sonoanatomy identification accuracy compared to the control group immediately following training, but not at follow-up. Gel Phatom Baseline Teaching Video Three-week Retention Baseline Three-week Retention Control Baseline Three-week Retention Spinous process (%) 100.00 93.3 100.0 100.0 86.7 100.0 Lamina (%) 88.2 66.6 72.2 47.5 40.0 50.0 Transverse Process (%) 76.5 13.3 77.8 17.6 33.3 33.3 [Performance of Spinal Sonoanatomy Identification] Logistic regression analysis, controlling for faculty status, age, and anesthesia and ultrasound experience, demonstrated both interventions improved the odds of transverse process (gel 12.61, p = 0.013; video 7.93, p = 0.030) and lamina (gel 65.12, p = 0.003; video 8.97, p = 0.031) identification. Perceived knowledge of basic spinal anatomy and spinal sonoanatomy improved in the intervention versus control groups. [Perception of spine sonoanatomy knowledge] Intervention group participants rated both teaching modalities as highly satisfactory. Mean (SD) modified Likert scale scores (1=“unsatisfied”, 10=“very satisfied“) were 8.12(1.50) and 8(1.68) for hands-on gel phantom and instructional video training participants, respectively. Discussion: Use of either hands-on gel phantom or instructional video training can improve anesthesia staff and resident knowledge of lumbar spine sonoanatomy. Identifying these structures may improve neuraxial anesthesia placement. Future studies are necessary to assess training modality effects on performance benefits in obese patient populations and those with abnormal spine anatomy. References: 1.Chin et al, Anesthesiology 2011; 115:94-101 2.Grau et al, Reg Anesth Pain Med 2001; 26:64-67 3.Li et al, J Ultrasound Med 2011; 30:263-272. Funding Support: Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health Authors have no disclosures. A42 ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK AS UNIQUE ANALGESIC FOR CESAREAN SECTION J.S. Vilchis Rentería, M.D. González Guzmán, A.M. Romero González, A.F. Cuéllar Lopez Hospital Materno Infantil de Alta Especialidad, Guadalupe, Mexico Introduction: The standard multimodal analgesic for cesarean section is the epidural morphine; the ultrasound guided transversus abdominis plane (TAP) block, which entirely blocks the sensory innervation of the anterior abdominal wall, also eliminates the undesirable effects of morphine and provides a satisfactory managed postoperative analgesia in multimodal regimes. We assess the analgesic efficacy of TAP block up to 8 days of the postoperative period as unique analgesic, compared with morphine epidural for the cesarean delivery. Methods: A prospective, randomized study, prior informed consent and Institutional Review Board approval, was made in 40 healthy patients with term pregnancy scheduled for elective cesarean section, divided into two groups: Morphine Group (n = 20) and TAP Group (n = 20). All patients received epidural block with 400 mgs. of 2% lidocaine plus epinephrine 1:200,000. At the end of the surgery, morphine group were administered 1.5 mgs. of epidural morphine; in TAP group was performed bilaterally ultrasound guided TAP block with 75 mgs. of ropivacaine at 0.325% (20 ml volume) on each side. The intensity of pain was evaluated at 4, 12, 24, 48 hours and 8 days of the postoperative using Visual Analog Scale (VAS). The Wilcoxon test and the Pearson coefficient for study of correlations were chosen for the validation of comparisons. Results: Demographic parameters were homogeneous in both groups. On measurements of pain post operative VAS average were lower than 3 in both groups, without a statistically significant difference. The average of VAS was greater in the group of epidural morphine: 2.7, and 0.95 in the transverse plane block group at 48 hours (P = 0. 002). The 4 hrs., 12 hrs., 24 hrs. and 8 days averages of VAS did not increase in the TAP group, reported no significant differences (P > 0.05); while in the morphine group was presented a slight increase in the scale of VAS at the 24 hrs., although without being significant. Discussion: The use of the ultrasound guided TAP block for postoperative analgesia in cesarean section offers an adequate pain control, keeping average of EVA low with the passage of time from 48 hours up to 8 days compared to the use of epidural morphine postoperative. [VAS BY MEASURING TIME] References: 1. McDonnell J.G., Curley G., Carney J., Benton A., Costello J. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg. 2008; 106: 186-91. 2. Kanazi G.E., Aouad M.T., Abdallah F.W., Khatib M.I., Adham A.M. Harfoush D.W. The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg. 2010; 111: 475-481. 3. Belavy D., Cowlishaw P.J., Howes M., Phillips F. Ultrasound guided transversus abdomins plane block for analgesia after caesarean delivery. Br J Anaesth. 2010; 103(5): 726-730. Personal funding made the present work and there is nothing to disclose. A43 SCIATIC NERVE BLOCK BENEFICIAL WHEN COMBINED WITH FEMORAL NERVE BLOCK FOR TOTAL KNEE ARTHROPLASTY 1 2 1 1 D. Dillane , D. Sriramatr , S. Rashiq , B. Tsui 1 2 Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada, Anesthesiology, Srinakharinwirot University, Bangkok, Thailand Current best evidence indicates that single shot femoral nerve blockade as part of a multimodal regime is the most appropriate way of managing pain after total knee arthroplasty(1). There is not enough evidence to recommend adding a sciatic nerve block to a single-shot femoral nerve block. Continuous femoral nerve blockade cannot be recommended based on current evidence. In this study we retrospectively reviewed the medical records of all patients who underwent TKA at our institution over a 5 year period when analgesia after TKA transitioned from parenteral opioids to peripheral nerve blockade. We specifically investigated the efficacy of the principal means of analgesia and its effect on length of stay. Research Ethics Committee approval was obtained. Recorded variables included age, gender, length of stay, administration of femoral and sciatic nerve block, patient controlled analgesia (PCA) use and Visual Analogue Pain (VAS) scores on Days 0 - 2. Length of stay and VAS scores were compared between groups using ANOVA, followed by Tukey's post hoc test for intergroup differences. The medical records of 983 patients who underwent TKA during the study period were examined (Table 1). All regional techniques had significantly better VAS scores on Day 0 when compared with no block (Figure 1). Addition of a single shot sciatic block to a femoral catheter technique significantly improved VAS score on Day 0 when compared with femoral catheter technique alone. Femoral catheter with or without a single shot sciatic block was associated with significantly lower VAS scores when compared with single shot femoral blocks on Day 1. This improvement did not persist to Day 2. A single shot femoral block significantly reduced length of stay by 1 day when compared with no block (Figure 2). A combined femoral catheter and single shot sciatic technique significantly reduced length of stay by 1.5 days when compared with no block. This study shows the analgesic benefit at Day 0 of adding a single shot sciatic block to a continuous femoral technique. Even though LOS was reduced by 1.5 days when a combined femoral / sciatic technique is compared with no block, this does not compare favorably with the currently reported LOS mean of 3 - 4 days (2). This may be due to a large dose of highly concentrated local anesthetic contributing to post-operative quadriceps weakness and delayed rehabilitation. More active management of a continuous femoral catheter technique may preserve its significant effect on postoperative pain while leading to a further reduction in LOS. 1. Paul JE et al. Anesthesiology. Nov;113(5):1144-62. 2. Salinas FV et al. Anesth Analg. 2006 Apr;102(4):1234-9 No Sciatic Block Single-Shot Sciatic Block Total No Femoral Block 565 0 565 (58%) Single-Shot Femoral Block 123 15 138 (14%) Femoral Catheter 75 205 280 (29%) Total 763 (78%) 220 (22%) 983 (100%) [Table 1. Number of Patients By Block Type] [Figure 1. Mean VAS Scores on Day 0, 1 and 2] [Figure 2. Mean Length of Stay (Days)] A44 BODY MASS INDEX (BMI) DOES NOT AFFECT TIME TAKEN OR SUCCESS RATE WHEN SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK IS PERFORMED WITH ULTRASOUND GUIDANCE 1 2 1 1 D. Dillane , D. Sriramatr , S. Rashiq , B. Tsui 1 2 University of Alberta, Edmonton, AB, Canada, Anesthesiology, Srinakharinwirot University, 3 Bangkok, Thailand, Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Regional anesthesia in the obese patient can be challenging. A retrospective analysis of 2020 nerve stimulator guided supraclavicular blocks demonstrated that obesity was associated with a decrease in success rate and an increase in relative difficulty (1). Schwemmer did not find a significant difference in success rates for ultrasound guided interscalene blockade (2). In this retrospective study we reviewed data from our acute pain database from the past year. All patients who underwent ultrasound + nerve stimulation guided supraclavicular brachial plexus blocks for hand surgery were included to determine if BMI was associated with time taken or success rate. Research Ethics Committee approval was obtained. Variables included age, gender, height, weight, practitioner grade, time to perform the pre-block scan and the block, volume of local anesthetic mixture, necessity for, timing of and type of supplemental blockade and the necessity for general anesthesia. Block failure was defined as necessity for general anesthesia or any supplemental nerve blockade following the supraclavicular block. 135 patients were reviewed (Table 1). There was no correlation between BMI and block/scan time, adjusted for practitioner grade (Pearson's r=0.09, p=0.27). We modeled block failure as composite binary outcome using logistic regression. Indicator variables were created for BMI < 25, BMI 25 to < 30 and BMI ≥ 30. Staff anesthesiologist performance was used as the reference category for practitioner grade. Gender was also included. The model's c statistic was 0.726 (Table 2). BMI did not appear to influence block performance time or failure rate when ultrasound was combined with nerve stimulation. Block success rates were not influenced by practitioner grade. This may have been a selection effect. Female gender was associated with higher block success. Further analysis revealed that females received 16% more local anesthetic per kilogram (p=0.0058) which may explain this unexpected finding. Age (mean±SD) 36±16 Gender (M:F) 112:23 Weight (Kg, Mean ±SD) 84±20 BMI (Kg/m2 Mean±SD min-max 27.5±5.6 15.1 - 46.7 Number of Staff 21 Number of Fellows 46 Number of Residents 68 Pre-block scan time (mins:mean, min-max) 1.3, 0 - 9 Block time (mins:mean, min-max) 4.7, 2 - 15 Total time (mins:mean, min-max) 6.0, 3 - 6 [Table 1. Clinical characteristics of sample n= 135] Odds of block failure 95% C.I. (Lower) 95% C.I. (Upper) P value Male Gender Reference Reference Reference Reference Female Gender 0.08 0.01 0.63 0.017 Staff anesthesiologist Reference Reference Reference Reference Fellow 1.35 0.44 4.11 0.602 Resident 0.45 0.15 1.35 0.155 BMI < 25 Reference Reference Reference Reference BMI 25 - 30 1.21 0.47 3.10 0.692 BMI > 30 1.74 0.64 4.73 0.278 [Table 2. Results of logistic regression model] 1. Franco CD. Anesth Analg. 2006 Apr;102(4). 2. Schwemmer U. Ultraschall Med. 2006 Jun;27(3). A45 INJECTION PRESSURE MONITORING RELIABLY DETECTS NEEDLE-NERVE CONTACT DURING ULTRASOUND-GUIDED INTERSCALENE BRACHIAL PLEXUS BLOCK J. Gadsden, J. Choi, E. Lin, A. Robinson, A. Shariat Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York, NY, USA Introduction: While US guidance during peripheral nerve blockade (PNB) has improved success 1 rate, neurologic complications continue to occur. Needle-nerve contact and/or intraneural injection 2,3 during PNBs have been shown to lead to nerve inflammation and/or injury. The objective of this study is to evaluate the utility of injection pressure monitoring as a useful adjunct for detecting needlenerve contact. Methods: Following IRB approval and informed consent, 7 adult patients (with BMI < 35 and adequate sono-anatomy) scheduled for shoulder surgery under interscalene block (ISB) were recruited for this ongoing study. Under ultrasound guidance, a 22 G stimulating needle was sequentially placed in three locations (1 mm from the trunk, needle-trunk contact, and disengagement of needle-trunk contact to 1 mm), Figures 1 & 2. [Figure 1] [Figure 2] At each location, the current (0.1 msec, 2 Hz) required to maintain motor response and the opening injection pressure (OIP) required to initiate an injection of 1 mL D5W were recorded using an in-line manometer (PendoTECH, Princeton, NJ) coupled to a computer via an analog-to-digital conversion board (PressureMAT, PendoTECH, Princeton, NJ) and to a disposable injection pressure monitor (BSmart, Concert Medical, Norwell, MA). Injectate was administered via an automated infusion pump (PHD 2000, Harvard Apparatus, Holliston, MA) at 10 ml/min. Blinded investigators performed evaluations and aborted injections when an opening injection pressure of 15 psi was reached. Results: Minimum current required to maintain motor response varied widely and overlapped between needle placements 1 mm from the nerve trunk (0.3-3.5 mA) and needle placements contacting the nerve trunk (0.1-1.9 mA). Overall, a current of 0.5 mA detected needle-nerve contact in 6 of 7 (86%) patients and paresthesia occurred in 2 of 7 (28%) patients, whereas opening injection pressure ≥15 psi detected all (100%) needle-nerve contacts. Discussion: While electrical current (0.5 mA) detected needle-nerve contact in 86%, and paresthesia in 28%, injection pressure monitoring (≥15 psi) detected all occurrences of needle-nerve contact. In conclusion, the combination of US, nerve stimulation, and injection pressure monitoring detected needle nerve contact and prevented injection against the nerve in all occurrences of needle-nerve contact during ISB. References: 1. Cohen JM, Gray AT. Functional deficits after intraneural injection during interscalene block. Reg Anesth Pain Med 2010;35:397-9 2. Lupu CM, Kiehl TR, Chan VWS, El-Beheiry H, Madden M, Brull R. Nerve expansion seen on ultrasound predicts histologic but not functional nerve injury after intraneural injection in pigs. Reg Anesth Pain Med 2010;35:132-9 3. Steinfeldt T, Graf J, Schneider J, Nimphius W, Weihe E, Borgeat A, Wulf H, Wiesmann T. Histological consequences of needle-nerve contact following nerve stimulation in a pig model. Anesthesiol Res Pract 2011; epub April 19 2011 Funding: Departmental. A46 DURATION OF ANALGESIC EFFECTIVENESS OF THE POSTERIOR AND LATERAL TAP BLOCK TECHNIQUES FOR TRANSVERSE LOWER ABDOMINAL INCISIONS: A METAANALYSIS F.W. Abdallah, J.G. Laffey, S.H. Halpern, R. Brull Anesthesiology, University of Toronto, Toronto, ON, Canada Background: Both the posterior (triangle of Petit) and lateral (mid-axillary line) approaches to the transversus abdominis plane (TAP) block, provide effective early (0-12 hours) postoperative analgesia 1 following surgery involving a transverse incision. However, whether the posterior or lateral TAP block can produce prolonged analgesia lasting beyond the first postsurgical 12 hours remains 2 controversial. This meta-analysis examines the duration of analgesia associated with each of the posterior and lateral TAP block approaches in the first 48 hours following surgery using a lower abdominal transverse incision. Methods: We searched MEDLINE; Embase; Cochrane Database of Systematic Reviews; and Cochrane Central Register of Controlled Trials databases for randomized controlled trials (RCTs) investigating the analgesic effects of TAP block compared to placebo or systemic analgesia (control group) in patients undergoing abdominal surgery using a lower abdominal transverse incision. Outcomes sought included interval postoperative intravenous morphine consumption as well as rest and dynamic pain scores at 12, 24, 36, and 48 h postoperatively. We also assessed the opioid-related side effects and patient satisfaction at 24 and 48 h. The 12-24 h interval postoperative morphine consumption was designated as our primary outcome. Random effects modeling was used to combine the results. Results: Twelve RCTs including a total of 641 patients were analyzed. Four of the trials examined the posterior technique, and eight assessed the lateral technique. Compared to the control group, the posterior TAP block reduced postoperative intravenous morphine consumption during the 12-24 and 24-48h intervals by 11.3 mg (95% CI: -16.61, -5.89; P< 0.0001) and 5 mg (95% CI: -9.54, -0.52; P=0.03), respectively (Figure 1); reduced rest pain scores at 24, 36, and 48 h by 13 mm (95% CI: 21.7, -3.8; P=0.005), 18 mm (95% CI: -22.7, -12.9; P< 0.00001) and 15 mm (95% CI: -20.2, -8.9; P< 0.00001), respectively (Figure 2). The posterior TAP block reduced dynamic pain scores at 12, 24, 36 and 48 h by 16 mm (95%CI: -18.8, -13.0; P< 0.00001), 22 mm (95% CI: -32.8, -11.0; P< 0.0001), 12 mm (95% CI: -18.7, -5.2; P=0.0006), and 22 mm (95% CI: -33.2, -11.2; P< 0.0001), respectively; and, reduced the incidence of sedation at 24 and 48 h by 59.5% (95% CI: 0.10, 0.57; P=0.001) and 100% (95% CI: 0.00, 0.63; P=0.02), respectively. In contrast, the lateral TAP block did not reduce morphine consumption, rest or movement pain scores or sedation scores compared to control groups at any of these time points. Conclusion: Based on the comparison of both techniques to control, the duration of analgesia following the posterior TAP block for abdominal surgery via a lower abdominal transverse incision is greater than the lateral TAP block. These findings may be partially explained by a retrograde paravertebral spread of local anesthetics reaching the thoracolumbar sympathetic chain. [Figure 1: Forest plots of morphine consumption for] [Figure 2: Rest pain at A, 24 h. B, 36 h. C, 48 h.] A47 SUCCESS RATE OF PERINEURAL INFRA-CLAVICULAR BRACHIAL PLEXUS CATHETERS: RANDOMIZED CONTROLLED SINGLE BLIND TRIAL COMPARING PERIPHERAL NERVE STIMULATION WITH ULTRASOUND GUIDED CATHETER PLACEMENT S. Dhir, S. Ganapathy Anesthesia and Perioperative Medicine, Western University, London, ON, Canada Introduction and objectives: Peripheral nerve stimulation (PNS) and ultrasound-guided placement techniques have been described for infraclavicular brachial plexus perineural catheters(1, 2). We tested the hypothesis that US guided catheters produce better block success. The secondary hypothesis was that infraclavicular catheters placed using only ultrasound guidance require less time for placement when compared with catheters placed using only PNS. Materials and methods: A total of 210 patients undergoing elective hand or elbow surgery were randomly allocated to receive continuous infraclavicular brachial plexus block using ultrasound guided needle and catheter placement (group US, n=105) or PNS guided stimulating needle and catheter placement (group ST, n=105). Posterior cord stimulation was considered to be an end point in ST group whereas spread of drug in the posterior cord location as observed by ultrasound imaging was an end point in US group. All drug was administered through the catheter in both groups. Motor and sensory blocks were assessed every 5 min and block success was determined at 30 min. Complications and need for intraoperative supplements were noted. Primary outcome was block success at the end of 30 minutes. during the surgery. The secondary outcomes were block success for surgery, intraoperative analgesia requirement and the catheter insertion duration (minutes) starting when the needle entered the patient skin and ending when the drug injection via the placed catheter ended. Results and discussion: Due to protocol violations, 8 patients were not included in analysis. Catheters placed with ultrasound guidance took a significantly shorter time (mean 7.0 (±2.5) minutes compared with 10.5 (±3.6) minutes for stimulation (P < .01). In 5 patients of US group and 16 in ST group, we were unable to establish a complete block and this was statistically significant (p< .001). On sub group analysis, all successful blocks in ST group had a posterior cord twitch elicited from needle or catheter or both versus lateral cord in those that were unsuccessful. In three patient from ST group, the catheter had to be placed with US guidance as no twitches could be elicited. One patient from ST group had vascular puncture leading to hematoma formation. This block was successfully done with US guidance. There was no difference in procedure-related pain scores and satisfaction. Conclusions: In this prospective randomized controlled single blind trial, we found that placement of infraclavicular perineural catheters is more successful with ultrasound guidance and takes less time. Interestingly, we found out that if PNS stimulation is used for guidance and posterior cord twitch is elicited via the stimulating catheter, there is no difference in block success rate. References: 1. Mariano ER et al. Ultrasound Guidance Versus Electrical Stimulation for Infraclavicular Brachial Plexus Perineural Catheter Insertion. J Ultrasound Med 2009; 28:1211-1218. 2. Slater ME, Williams SR, Harris P, et al. Preliminary evaluation of infraclavicular catheters inserted using ultrasound guidance: through-the-catheter anesthesia is not inferior to through-the-needle blocks. Reg Anesth Pain Med 2007; 32:296-302. Funding: The entire project was funded by Physicians Services Incorporated Foundation, Canada. A48 THE ROLE OF THE SAPHENOUS NERVE IN DISTAL TIBIA AND MEDIAL ANKLE JOINT CAPSULE INNERVATION: A CADAVER STUDY J.-L. Horn, N. Eglitis, S. Nelsen 1 2 Anesthesiology and Perioperative Medicine, Integrative Biosciences Department, Oregon Health and Science University, Portland, OR, USA Introduction: The saphenous nerve provides cutaneous innervation to the skin and soft tissues 1 overlying the medial and anterior lower leg . Our clinical experience suggests that adding a saphenous nerve block to a sciatic nerve block is necessary to obtain complete anesthesia and/or analgesia of the ankle even when the overlying skin remains undisturbed. The goal of this study is to determine the role of the saphenous nerve in the innervation of the distal tibia and the medial ankle joint capsule. Material and methods: This study was approved by the OHSU institution review board. Twenty-five lower legs from thirteen embalmed cadavers were dissected. The cadavers were between the ages of 59-100; five were male and eight were female. Each lower leg was opened with a superficial skin flap extending distally from the lateral border of the proximal tibia to the dorsum of the foot and then reflected medially to expose the medial and anterior portions of the lower leg. The saphenous vein was identified along with the accompanying nerve. The nerve was then followed along its distal course and branches deep to the subcutaneous tissue were identified and dissected. Results: All samples had an identifiable saphenous vein and nerve. Each ankle also had at least one deep branch off the saphenous nerve diving deep and medial becoming continuous with the periosteum of the distal tibia. These branches divide from the saphenous nerve between 4-8 cm above the medial malleolus. All ankles also had identifiable branches, which become continuous with the capsule of the ankle joint around the medial malleolus. (Fig. 1) [fig. 1] Discussion: This cadaver study proposes that the saphenous nerve innervates the periosteum of the distal tibia and medial ankle joint capsule. Deep branches of the saphenous nerve to the ankle are difficult to identify upon routine dissection due to their fragility and small size, however they are important clinically as they likely contribute to the sensory innervations of bony structures from the medial ankle. As such, regional anesthetic techniques applied of the medial ankle should include the addition of a saphenous nerve block to the sciatic nerve block. References: 1 Williams PL, Bannister LH. Gray's Anatomy: The Anatomical Basis of Medicine and Surgery. 38th ed. New York, NY: Churchill Livingstone, 1995 Funding: Internally funded by the Department of Anatomy and the Department of Anesthesiology and Perioperative Medicine A49 STIMULATING CATHETERS DO NOT IMPROVE THE EFFECTIVENESS OF LUMBAR PLEXUS BLOCK COMPARED WITH TRADITIONAL NONSTIMULATING CATHETERS. A PROSECTIVE, RANDOMIZED DOUBLE BLINDED STUDY 1 2 1 2 2 1 L. Guzzetti , E. Basso Ricci , S. Turconi , F. Ruggieri , P. Ghisi , A.L. Ambrosoli , G. Cappelleri 1 2 2 Anesthesiology, Università degli Studi dell'Insubria, Varese, Università degli Studi di Milano, Milan, 4 Ospedale di Circolo Università dell'Insubria, Varese, Istituto Ortopedico Gaetano Pini, Milan, Italy 3 Introduction: Our prospective, randomized, double blinded study aims to detect if stimulating catheters decrease the minimal effective volume (MEAV) of 1.5% mepivacaine for successful lumbar plexus block (LPB) in 50% of patients compared with traditional non-stimulating catheters. Materials and methods: After local ethics committee approval and written informed consent 50 ASA I-III patients scheduled for primary, unilateral total hip arthroplasty were enrolled in the study and randomized in two different groups. One group received continous lumbar plexus block by stimulating catheter (group S: 25 patients) and one by nonstimulating catheters (group NS: 25 patients). To calculate the MEAV 50 the up and down Dixon´s starcaise method was applied (p < 0.05 was considered statistical significant). Results: No differences in anthropometric data were found between the groups. The MEAV50 calculated in continuous lumbar plexus block was 27,40 ml (95% CI, 24,1-30,6) of 1,5% mepivacaine in group S, and 26 ml (95% CI, 24,2-27,7) of 1,5% mepivacaine in group NS (p = 0.145).(Fig.1) [Fig.1] The time for catheter placing was statistically different: 180 (range 130-240) sec in the group S while 120 (range 95-180) sec in the group NS (p < 0.030); while no difference was found in obturator nerve block. Discussion: This prospective, randomized, blinded evaluation shows that stimulating catheters do not reduce the minimum effective volume of local anesthetic (MEAV) required for lumbar plexus block. Stimulating catheters have been advocated to minimize catheter misplacement and secondary block failure, as they have been described to guide catheter tip closer to the target than non-stimulating catheter (1). Our results do not support this hypothesis. Kirchmair and colleagues recently evidenced that lumbar plexus is located within the psoas muscles in 98% of cases in cadavers (2). This location could allows the spread of local anesthetic around the nerve even in case of progression of the catheter far away from the target nerve. Moreover, in the present study non-stimulating catheter tips were advanced only 2-3 cm over the needle tip, increasing the likelihood of proximity with the target nerve. In this study we observed bilateral spread of local anesthetic in one patient of group NS and two patients of group S. Curiously, in one of this latter case the postoperative x-ray do not showed any neuraxial spread of local anesthetic.(Fig.2) [Fig.2] In conclusion, stimulating catheters do not decrease the MEAV of 1.5% mepivacaine in patients undergoing continuous lumbar plexus block compared with nonstimulating catheters. Furthermore our study demonstrate that stimulating catheters do not prevent bilateral spread of local anesthetic and further study needed to increase the knowledge of lumbar plexus block. References: 1: Salinas FV et al. Prospective comparison of continuous femoral nerve block with nonstimulating cathteter placement versus stimulating cahteter-guided perineural palcemente in volunteers. RAPM 2004;29:212-20. 2: Kirchmair L et al. Lumbar plexus and psoas major muscle: not always as expected. RAPM 2008;33:109-14. Funding disclosure: Nothing to disclose. Personal conflicts of interest disclosure: Nothing to disclose. A50 THE CATHETER-OVER-NEEDLE ASSEMBLY FACILITATES DELIVERY OF A SECOND LOCAL ANESTHETIC BOLUS TO PROLONG SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK WITHOUT TIME-CONSUMING CATHETERIZATION STEPS V.H.Y. Ip, B.C.H. Tsui, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Supraclavicular brachial plexus block provides effective anesthesia for upper extremity surgery. Current evidence for supraclavicular blocks is based largely on studies of single-shot 1,2 techniques since catheterized delivery of supraclavicular blocks can be challenging and time1 consuming to perform, and dislodgement and ineffectiveness are common problems. Here, we demonstrate that a catheter-over-needle assembly can be used to deliver a supraclavicular block in the same time taken to give a single-shot block, and that retention of the catheter throughout surgery provides a means to deliver a second, post-operative bolus of local anesthetic, prolonging the analgesic effect. Material and methods: Patients were randomized into two groups: the control group received a single-shot supraclavicular block with 25-30 mL of local anesthetic (1.5% lidocaine and 0.125% bupivacaine mixture), while the study group received a supraclavicular block via a catheter-over3 needle assembly with the same volume and concentration of local anesthetic as in the single-shot block, followed by a second, post-operative bolus of analgesic solution (20 mL of 0.2 % ropivacaine) through the catheter prior to its removal (Figure 1-Arrows indicate the double-catheter assembly; asterisk, inner catheter tip; oval, brachial plexus (BP)). [CON assembly with the inner and outer catheter] Duration of time between initial bolus and onset of pain as well as duration of pain relief from last bolus were measured. Results: Thirty patients were enrolled and randomized into the single-shot supraclavicular block group (n=15) and the supraclavicular catheter group (n=15). One patient withdrew from the study, and five patients were lost to follow-up. We observed no significant difference in block times between the two groups (4.4 ± 2.7 min single shot vs. 3.1 ± 1.9 min catheter (p = 0.17)). Pain relief from initial bolus to onset of pain lasted, on average, 617.5 (± 288.0) minutes for patients receiving the second bolus compared to 377.2 (± 161.3) minutes for the single-shot control group (p=0.03). Discussion: Importantly, delivering the supraclavicular block through the catheter took no more time than the single-shot approach. Furthermore, the catheter was stable and remained in place throughout surgery. These results suggest that placement of a catheter-over-needle assembly can be an efficient method for delivering a supraclavicular block as well as providing a means to supplement prolong the analgesic effect following discharge. References: 1. Heil JW et al. J Ultrasound Med. 2010; 29: 1481-5 2. Mariano ER et al. Reg Anesth Pain Med. 2011; 36: 26-31 3. Ip V et al. Can. J. Anesth. 2012; 59: 1125-9 Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest: The Pajunk MultiSet 211156-40E is modified and re-designed by Dr. Ban Tsui. Dr. Tsui also has a patent-licensing agreement with Pajunk. A51 MEPIVACAINE AND FENTANYL FOR SPINAL ANESTHESIA: A DOUBLE BLINDED RANDOMIZED DOSE-RESPONSE TRIAL R.L. Kahn, J.J. Bae, J.T. Ya Deau, J.G. Muller, J. Gonzalez, G.A. Liguori, J.D. MacGillivray, H.A. Rose, R.J. Williams III, J. Curren, E. Chen, K. Fields Hospital for Special Surgery, New York, NY, USA Introduction: Thirty mg isobaric mepivacaine 1.5% plus 10 µg fentanyl produces reliable anesthesia for knee arthroscopy, and has a more rapid recovery profile than 45 mg mepivacaine alone (1). This study examined the dose-response of mepivacaine with and without fentanyl for spinal anesthesia. Material and methods: Following written informed consent, subjects having out-patient knee arthroscopy were prospectively randomized into one of 4 groups: mepivacaine 37.5 mg (group 37.5); mepivacaine 30 mg plus fentanyl 10 µg (30/10); mepivacaine 27 mg plus fentanyl 10 µg (27/10); and mepivacaine 24 mg plus fentanyl 10 µg (24/10). Success or failure of the spinal was judged by the anesthesia provider and the surgeon blinded to group assignment. In the post-anesthesia care unit, subjects were assessed every 15 minutes for sensory and motor block resolution by a blinded research assistant. Prior to discharge, subjects rated their satisfaction with the OR experience, on a 1 to 10 scale (0 = very dissatisfied, 10 = very satisfied). Primary outcome was the duration from spinal injection to ambulation. Results: Fifty-six subjects were analyzed. Group 30/10 had 2 of 6 “fair” anesthetics and group 27/10 had 1 “fair” and 1 “inadequate” after 10 subjects, thus both were eliminated from further enrollment per study protocol. Groups 37.5 and 24/10 had 1 “fair” anesthetic each, out of 22 and 18 subjects, respectively. The recovery profiles showed little difference between groups 37.5 and 30/10 (except faster resolution of motor block). Groups with lower doses of mepivacaine, 27/10 and 24/10, demonstrated a shorter time to achieve recovery milestones than group 37.5. Discussion: All groups had at least one incomplete anesthetic. The 3 fentanyl groups had a combined incidence of 5/34 (15%, 95% CI 2.8 - 26.2%). Compared to the group 37.5, groups 27/10 and 24/10 had a recovery profile that was faster by approximately 30 minutes. This advantage of a quicker recovery must be weighed against the probability of an incomplete anesthetic. References: 1. Can J Anaesth. 2010 Jan;57(1):32-8 Funding: Department of Anesthesiology, Hospital for Special Surgery The authors declare no conflicts of interest M37.5 (N = 22) M30/F10 (N = 6) M27/F10 (N = 10) M24/F10 (N = 18) Total (N = 56) Anesthesia Rating, N 15/6/1/0 Perfect/Good/Fair/Inadequate 3/1/2/0 7/1/1/1 14/3/1/0 39/11/5/1 Surgeon's Rating, N Perfect/Good/Inadequate 15/6/1 4/0/2 6/2/2 15/3/0 40/11/5 Patient Satisfaction with Anesthesia, mean (SD) (0 = worst, 10 = best) 9.9 (0.5) 10 (0) 9.9 (0.3) 10 (0) 9.9 (0.3) Anesthesia Rating: Perfect=No response to surgery; Good=Minimal response controlled with conscious sedation including up to 100 µg fentanyl; Fair=Requiring deep sedation; Inadequate=Requiring general anesthesia; Surgeon's Rating: Perfect=No movement or patient response; Good=Minimal movement; Inadequate=Unacceptable movement [Table 1: Rating of spinal block] G1 M37.5 (N = 22) G2 M30/F10 (N = 6) P (G1 vs G2) G3 M27/F10 (N = 10) P (G1 vs G3) G4 M24/F10 (N = 18) P (G1 vs G4) Time, min, mean (SD) From Induction End To: Modified Bromage Scale of 0 161 (40) 127 (14) 0.033* 102 (35) 0.003** 99 (35) 0.0002** Sensory Block Regression to Dermatome Level S1 200 (38) 197 (27) 0.857 161 (32) 0.017* 162 (30) 0.006 ** First Ambulation 225 (36) 215 (32) 0.538 178 (25) 0.004** 179 (31) 0.002 ** First Urination (>100 mL) 226 (35) 227 (38) 0.970 198 (35) 0.053 191 (41) 0.014* Actual Discharge 261 (43) 257 (40) 0.859 227 (31) 0.034* 220 (40) 0.011* NRS pain score, mean (SD) (0 = none, 10 = worst) Average 1.8 (1.5) 0.3 (0.5) 0.013* 0.7 (0.7) 0.033* 1.3 (1.7) 0.181 Worst 2.7 (2.1) 1.0 (1.5) 0.035* 1.4 (1.3) 0.078 2.6 (2.7) 0.603 [Table 2: Block characteristics by study group] [Figure 1: Outcome distribution by study group] A52 A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL ON THE EFFECTS OF ULTRASOUND PROBE POSITION ON ULTRASOUND GUIDED NERVE BLOCK 1 1 1 2 1 1 1 1 N.C.K. Lam , E.B. Baker , S. Fishburn , E. Mariano , E. Szabo , F. Jaime , A. Hammer , T. Petersen 1 Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, 2 NM, Anesthesiology, Stanford, Stanford, CA, USA Introduction: Proper needle visualization is imperative in achieving a successful anesthetic outcome. 1 At present, there are 2 basic probe positions that are being taught in the major teaching institutes in the world. One technique involves a probe position perpendicular to the individual performing block and the other involves a probe position parallel to the individual performing the block. This study was designed to demonstrate if one technique is superior to the other in novices. Methods: Healthy, right handed volunteers who were 18 years of age or older with no prior training with ultrasound equipment were recruited. Thirty participants were randomized to two groups. Group PEN received training using an instructional video that demonstrated probe position perpendicular to the blocker (Figure 1). Group PAR received training using an identical instructional video that demonstrated probe position parallel to the blocker (Figure 2). [Figure 1] [Figure 2] 2 Standardized phantoms were made of gelatin. Three straws were glued at a standardized diagonal on the short axis such to simulate the neural structures in the interscalene region. The straws were also glued at a standardized tilt on the long axis straws to produce the effect of anisotropy. Each participant was asked to insert a 22G 80 mm Pajunk echogenic needle towards the 12'oclock position of each straw in sequence using Esaote MyLab 1 ultrasound.They were asked to stop needle advancement whenever the needle was not completely in view or when the targets (straws) were not at their maximum brightness. This process was timed and viewed by the same assessing anesthesiologist using a remote screen for the 30 participants. The participants repeated the task 3 times. The participant, assessing anesthesiologist and statistician were blinded to the participants´ allocation. Results: Participant performance was assessed by both time to completion (TTC) and the amount of procedural time in which the needle was not visible (NNS) on the ultrasound screen. Time measurements were truncated at 1000 seconds. Results for Time to completion (TTC) of task for groups PAR and PEN Video Task 1 TTC (seconds) Task 2 TTC (seconds) Task 3 TTC (seconds) Perpendicular (PEN) 87.5 78.6 65.5 Parallel (PAR) 638.3 543.6 466.8 Results for NNS as a proportion of time to completion for groups PAR and PEN Video Task 1 NNS (%) Task 2 NNS (%) Task 3 NNS (%) Perpendicular (PEN) 52 50 47 Parallel (PAR) 87 84 79 [Results of TTC and NNS] Discussion: It appears from our results that the group that was trained using the perpendicular probe position, is clearly superior in terms of time to completion and the percentage of time that the needle is seen. References: 1. Hadzic A. et al.: Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia. 2012;392. 2. Li JW. et al: Gelatin-agar lumbosacral spine phantom: a simple model for learning the basic skills required to perform real-time sonographically guided central neuraxial blocks. J Ultrasound Med 2011. Feb;30(2):263-72. A53 THE ADDUCTOR CANAL BLOCK PROVIDES ANALGESIA SIMILAR TO A FEMORAL NERVE BLOCK IN PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY - A RETROSPECTIVE STUDY M.E. Patterson, K. Bland, C. Elliot, S. Jayaswal, J. Soberon, L. Thomas, K. Osteen Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA Background: Following total knee arthroplasty (TKA) a femoral nerve block (FNB) is commonly used to provide analgesia (1), but its primary limitation is quadriceps weakness, which can limit physical therapy. An adductor canal block (ACB) has been shown to be effective in providing analgesia following knee surgery (2,3). Several nerves that innervate the knee traverse the adductor canal (4,5). Unlike the FNB, the ACB is primarily a sensory block with little motor involvement. However, evidence comparing the ACB to the FNB after TKA is lacking. The present study was performed to analyze the ability of an ultrasound guided ACB to provide adequate analgesia as compared to the FNB in patients undergoing TKA. Methods: The study was a retrospective chart review of patients that had a primary unilateral TKA between the dates of 7/1/12-10/31/12. Patients included in the study received either an ultrasound guided single-shot ACB or a femoral nerve catheter (FNC). The local anesthetic for the ACB was 1530cc of 0.375 or 0.5% Bupivacaine and for the FNC 30-40cc 0.25% Ropivacaine was bolused followed by a continuous infusion of 0.2% Ropivacaine. All patients received a Hydromorphone PCA. Pains scores, opioid consumption and rescue femoral nerve blocks were recorded in PACU and at 8±3 and 24±3 hours. Results: 60 patients received ACB and 51 patients received FNB; 47 (ACB) and 41(FNC) patients were included in the analysis. Patients were excluded from analysis because of incomplete medical records and 1 patient was unstable post-operatively unrelated to the nerve block. 91% (43/47) of patients had a successful ACB and did not need a rescue FNC in PACU. At 8 and 24 hours, 83% (39/47) and 70% (33/47) of patients did not require a rescue FNC, respectively. There was no difference in VAS scores between the ACB and FNC groups in PACU, at 8 hours and at 24 hours (Table 1). In addition, there was no difference in total hydromorphone used between the ACB and FNC groups in PACU, at 8 hours, and at 24 hours (Table 2). Discussion: This study demonstrates that an adductor canal block can provide analgesia as effectively as a continuous femoral nerve block, at least within the first 24 hours following TKA. VAS in PACU VAS at 8 Hr VAS at 24 Hr Adductor Canal Group 1.7±1.9 (n=43) 2.8±2.2 (n=39) 2.9±1.7 (n=33) Femoral Nerve Group 1.4±1.9 (n=41) 2.9±1.9 (n=41) 2.8±1.8 (n=41) P-Value 0.8 0.7 0.5 [Table 1. Pain Scores (Visual Analogue Scale)] Hydromorphone in PACU Hydromorphone at 8 Hr Hydromorphone at 24 Hr Adductor Canal Group 2.0±1.3 (n=43) 2.2±1.5 (n=39) 5.9±3.5 (n=33) Femoral Nerve Group 1.6±1.3 (n=41) 2.8±1.8 (n=41) 7.4±4.6 (n=41) P-Value 0.16 0.08 0.14 [Table 2. Cumulative Hydromorphone Usage (mg)] References: 1. Anesth Analg 1998;87:93-97. 2. Knee Surg Sports Traumatol Arthrosc. 2008;16(9):855-8. 3. Acta Anaesthesiologica Scandinavica. 56(8):1013-9, 2012 4. Anat Rec. 1948;101(1):109-30. 5. Clin Orthop Relat Res. 1994;(301):221-6. Funding: No manufacturer or third party funding Conflicts: Nothing to disclose A54 FUNCTIONAL OUTCOME FOLLOWING OUTPATIENT CONTINUOUS BRACHIAL PLEXUS BLOCK FOR COMPLEX ARTHROSCOPIC ELBOW SURGERY S. Riazi, C. Veillette, C. Tse, S. Abbas, V. Chan, A. Perlas 1 2 Anesthesia, Surgery-Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada Introduction: The primary surgical aim of complex arthroscopic elbow surgery (CAES) is to improve elbow range of motion. Immediate postoperative use of Continuous Passive Motion (CPM) equipment 1 plays a major role in acquiring optimal result and currently requires hospital admission for 72 hours. Continuous brachial plexus (CBP) analgesia enhances patient compliance with CPM, and surgical 1 outcome by effectively relieving pain and is the preferred method of analgesia in several centers. Outpatient management of CBP for less complex surgeries is associated with improved quality-of-life, 2 and cost-effectiveness. The goal of this study is to determine if early hospital discharge(23 hours after CAES) with ambulatory CPM and CPB result in similar surgical and functional outcome compared to standard inpatient-care. Material and methods: This is a prospective, randomized, single-blinded, non-inferiority comparative study. Following institutional research ethics approval, patients undergoing CAES were recruited, and consented. Patients were randomized into 2-groups using computer-generated randomization sequence. Surgical and anesthesia teams were blinded to group allocation until completion of surgery. An ultrasound-guided infraclavicular brachial plexus catheter was placed postoperatively, following neurovascular assessment by the surgeon. An initial bolus of 0.375% bupivacaine-30 mL was followed by an infusion of ropivacaine-0.2% via a disposable elastomeric pump, continued for 60 hours on all patients. Patients were treated equally in all care aspects(pre-operative, intraoperative, surgical approach, and CPM protocols), except for the discharge time. Group IP: Home-discharge 72 hours postoperatively. Patients received standard inpatient care. CBP was removed by an acute pain-physician 72-hours postoperatively (10 patients); Group OP: Home-discharge with CBP 23 hours postoperatively. Patients were followed by an acute pain-physician via daily telephone interviews and were given a 24-hour contact number. CBP was removed by the patient 72-hours postoperatively (10 patients). The primary outcome was the elbow range of motion “arc-ROM” (maximum flexion to extension) 2weeks after surgery. Pain scores and opioid consumption at postoperative days (POD)-1-3, as well as DASH (Disabilities of the Arm, Shoulder, and Hand), and Short Form 12 (SF12) scores at 2, 6, and 12 weeks were assessed. Results: This is an interim analysis of 20 patients for a projected n=40. Patient characteristics (gender, age, and BMI) were similar between two groups. There was no significant difference in pain scores, and morphine consumption on POD-1-3, as well as DASH score, and SF-12 at 2-weeks postoperatively between two groups. Both groups achieved equally satisfactory and similar arc-ROM at two weeks(118 +/-12 vs 124 +/-9). Discussion: These preliminary results suggest that outpatient management of CAES with ambulatory CPM and CBP is feasible and results in similar functional surgical outcome compared to current standard inpatient management. References: 1- O'Driscoll SW, Giori NJ.Continuous passive motion (CPM): theory and principles of clinical application. J Rehabil Res Dev. 2000:37:179-88. 2- Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesthesiology 2002: 96:1297-1304. Funding Disclosure: Drs. Riazi and Perlas receive academic time funding(Merit Awards) from the Department of Anesthesia, University of Toronto. Authors acknowledge equipment support from Philips, and Sonosite. A55 ULTRASOUND GUIDED PERI-ARTICULAR INFILTRATION ANALGESIA FOR PATIENTS UNDERGOING HIP ARTHROSOPY: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY S. Sinha, J. Abrams, S. Arumugam, J. Barnett, J. D'Alessio, D. Freitas, M. Joyce 1 2 Anesthesiology, Orthopedics, St. Francis Hospital and Medical Center, Hartford, CT, USA Introduction: Managing postoperative pain after hip arthroscopy in an ambulatory setting is a challenge. Even though peripheral nerve blocks provide adequate analgesia, they cause lower extremity weakness and increase the risk of falls(1,2). This study evaluated the analgesic efficacy of ultrasound-guided peri-articular infiltration oflocal anesthetic solution around the hip joint. Primary outcome measure was peri-operative opioid consumption; secondary outcome measures were pain scores, incidence of nausea/vomiting, time to discharge from post-anesthesia care unit (PACU) and patient satisfaction. Methods: Following IRB approval, 36 patients undergoing hip arthroscopy gave written, informed consent. Patients were randomized to receive either an ultrasound-guided peri-articular infiltration with 30mL of ropivacaine 0.5% with epinephrine 1:200,000 (Group R) or normal saline 30mL (Group N). After induction of general anesthesia (GA), with the patient in supine position, the hip joint was imaged with a transducer placed inferior and parallel to the inguinal ligament. Using an ultrasoundguided in-plane approach the lateral, anterior and medial aspect of the hip joint was infiltrated with 30ml of injectate. Intra-articular injection was avoided. GA was supplemented with fentanyl and hydromorphone as necessary by anesthesia care team. All patients received odansetron 4mg, dexamethasone 4mg and ketorolac 30mg. The portal sites were infiltrated with 20mL of bupivacaine 0.25% with epinephrine 1:200,000 by surgeon. After emergence from GA, in PACU, numeric pain scores (0-10) were recorded and intravenous hydromorphone was titrated for pain. Patients were discharged home from PACU when they met criteria and duration of stay was recorded. All patients were prescribed naproxen 550 mg every 12 hours and hydrocodone7.5mg+acetaminophen750mg tablets every 6 hours as needed for pain. At home, the patients recorded pain scores every 6 hour for 24 hours, pain tablet consumption, any episodes of nausea/vomiting and satisfaction with pain management. Results: Demographic variables were similar between groups. Patients in Group R received significantly lower amounts of hydromorphone intraoperatively and consumed fewer pain tablets at home.(Table1). Lower pain scores was reported on admission and discharge from PACU in Group R patients, however, pain scores at home were similar between groups.(Figure1) Patients in Group R were discharged earlier from PACU compared to Group N patients. Incidence of nausea/vomiting and patient satisfaction was similar between groups. Group N N=18 Group R N= 18 95% CI Differences p value Intraop Fentanyl (µg) median(min-max) 100 (75-200) 100 (100-200) -26.8 to 24.1 .63 Intraop Hydromorphone (mg) median(min-max) 1 (0.4-1.8) 0.5 (0-0.8) 0.2 to 0.7 *.01 PACU Hydromorphone (mg) median(min-max) 0.8 (0-2) 0.6 (0-1.6) -0.1 to 0.8 .12 PACU Time (minutes) Mean(±SD) 133.7 (±38.6) 110.6 (±28.3) 0.1 to 46.1 *.01 PACU N/V (Yes/No) 5/13 5/13 Home Hydrocodone +Acetaminophen (# of Tablets consumed) median(min-max) 4 (0-6) 3 (0-6) Home N/V (Yes/No) 2/16 6/12 [Table 1. HIP ARTHROSCOPY STUDY SUMMARY STATISTICS] 1.0 -0.01 to 2.5 .05 .23 [Figure 1] Discussion: Ultrasound-guided periarticular infiltration of ropivacaine reduces peri-operative opioid requirements, decreases pain scores in PACU and facilitates earlier discharge. References: 1. YaDeau et al. Anesth Analg 2012;115:968-972 2. Ward et al. Arthroscopy 2012;28:10641069 Funding: No External Funding A56 SPINAL ANESTHESIA DOES NOT IMPACT PROSTATE CANCER RECURRENCE IN A COHORT OF MEN UNDERGOING RADICAL PROSTATECTOMY 1 2 2 2 2 2 2 K.S. Tseng , S. Kulkarni , E.B. Humphreys , H.B. Carter , J.L. Mostwin , A.W. Partin , M. Han , C.L. 2 Wu 1 2 3 Anesthesiology, The Mount Sinai Hospital, New York, NY, Anesthesiology, Urology, Johns Hopkins Hospital, Baltimore, MD, USA Introduction: Prior studies have suggested a possible association between the use of neuraxial anesthesia and a decrease in prostate cancer recurrence after radical prostatectomy. Methods: After approval by the institutional review board, charts from consecutive radical prostatectomy patients of three experienced urologists from January 1999 to December 2005 were reviewed. In addition to the usual clinical and pathologic predictors of disease recurrence, patient records were also queried for the type of anesthesia (general versus spinal) performed. The 5- and 10-year biochemical recurrence-free survival (BFS) was calculated using the Kaplan-Meier methods. A Cox proportional hazards model was used to determine the statistical significance of predictors of biochemical recurrence. Results: A total of 1,970 patients - 1,172 and 798 receiving spinal and general anesthesia, respectively - had complete pre-operative and follow-up data. Men who had spinal anesthesia had a 5- and 10-year biochemical recurrence-free survival of 88.2% and 83.5%. Men who had general anesthesia had a 5- and 10-year BFS of 85.7% and 80.7% (figure 1). In univariate proportional hazards analysis, the use of general anesthesia was associated with a trend towards an increased risk of biochemical recurrence when compared with the use of spinal anesthesia (hazard ratio = 1.28, 95% confidence interval 0.99-1.65, p=0.055). However, when the type of anesthesia given was used in a multi-variable analysis, the effect size (hazard ratio = 1.10, 95% confidence interval 0.85-1.42, p=0.489) was diminished by clinical and pathologic variables. Discussion: This was a retrospective study of patients with prostate cancer who have undergone radical prostatectomy during a time period when the practice of anesthesia for prostatectomy at our institution was transitioned from spinal to general endotracheal anesthesia. In our study, when controlling for other predictors of advanced prostate cancer, the type of anesthetic given during prostatectomy had no effect on the risk of biochemical recurrence. Prior studies evaluating the oncologic benefit of regional anesthesia studied epidural anesthesia as an adjunct to general anesthesia versus general anesthesia alone. They found mixed results: either a 1 significant reduction in risk of biochemical recurrence ; a significant reduction in risk of clinical 2 3,4 recurrence, but not biochemical recurrence ; or no significant difference . To our knowledge, this is the first published study of spinal anesthesia as the primary anesthesia modality, as well as the largest cohort studied to date. The absence of a positive association between prostate cancer recurrence and spinal anesthesia in our study suggests that the relationship between neuraxial anesthesia and prostate cancer may have more facets than previously estimated. References: 1. Biki B, et al. Anesthesiology. 2008 Aug;109(2):180-7. 2. Wuethrich PY, et al. Anesthesiology. 2010 Sep;113(3):570-6. 3. Tsui BC, et al. Can J Anaesth. 2010 Feb;57(2):107-12. 4. Forget P, et al. Eur J Anaesthesiol. 2011 Dec;28(12):830-5 Funding: None Personal conflicts of interest disclosure: Nothing to disclose [Figure 1. Kaplan-Meier estimate ] Univariate HR (95% confidence interval) P-value Multivariate HR (95% confidence interval) P-value Age 1.00 (0.98-1.02) 0.874 0.99 (0.97-1.01) 0.413 PSA 10 ng/ml or greater (vs < 10 ng/ml) 3.47 (2.63-4.59) < 0.001 1.72 (1.28-2.33) < 0.001 Pathological Gleason sum 3+4=7 (vs 5/6) 3.94 (2.75-5.63) < 0.001 2.54 (1.74-3.70) < 0.001 4+3=7 (vs 5/6) 11.8 (8.20-17.1) < 0.001 5.90 (3.95-8.82) < 0.001 8-10 (vs 5/6) 15.3 (10.5-22.4) < 0.001 7.74 (5.11-11.7) < 0.001 Pathologic stage pT3a/b (vs pT2) 5.20 (3.90-6.95) < 0.001 3.01 (2.21-4.11) < 0.001 pT3c (vs pT2) 14.5 (9.72-21.7) < 0.001 5.12 (3.30-7.95) < 0.001 Lymph nodepositive (vs pT2) 17.0 (9.73-29.6) < 0.001 4.74 (2.63-5.58) < 0.001 General anesthesia (vs spinal) 1.28 (0.99-1.65) 0.055 1.10 (0.85-1.42) 0.489 [Table 1. Hazard ratio (HR) estimates] A57 REPLACING CONTINUOUS FEMORAL NERVE BLOCKS WITH CONTINUOUS ADDUCTOR CANAL BLOCKS WITHIN A CLINICAL PATHWAY FOR TOTAL KNEE ARTHROPLASTY: A CASE-CONTROL STUDY OF POSTOPERATIVE AMBULATION 1,2 1 1,2 1 1,2 1 1 J.J. Workman , T.E. Kim , S. Howard , S. Mudumbai , N. Giori , S. Woolson , T. Ganaway , E.R. 1,2 Mariano 1 Anesthesiology and Perioperative Care, VA Palo Alto Health Care System, Palo Alto, Anesthesiology, Stanford University, Stanford, CA, USA 2 Introduction: Continuous femoral nerve blocks have been shown to provide effective analgesia following total knee arthroplasty (TKA) and may decrease time to achieve discharge eligibility; however, there is a concern over quadriceps weakness which may contribute to patient falls. The adductor canal offers a more distal perineural catheter insertion site which may help spare quadriceps motor function without reduction in analgesia. The effects of continuous adductor canal blocks on functional outcomes have not been well-established. This case-control study tests the hypothesis that patients with continuous adductor canal blocks achieve greater maximum ambulation distance on postoperative day (POD) 1 compared to patients with continuous femoral nerve blocks within an established clinical pathway following TKA. Methods: With IRB approval and waiver of informed consent, we retrospectively examined the records of consecutive patients who underwent primary TKA over the course of one year, 6 months prior and 6 months after replacing femoral nerve catheters with adductor canal catheters as part of a clinical pathway. All other aspects of the clinical pathway (e.g., physical therapy regimen, nursing care, standardize analgesic medications) remained the same during this time period. We further refined our sample to include only cases performed by one surgeon with postoperative admission to the primary surgical ward and excluded cases which involved additional significant surgical procedures besides unilateral TKA. Our primary outcome was maximum ambulation distance (meters) on POD 1. Secondary outcomes included ambulation distance at each physical therapy session, daily opioid consumption, pain scores at rest and with movement during physical therapy, and hospital length of stay. For normally-distributed data, single comparisons were performed using Student's t test; for non-normal continuous data, the Mann-Whitney U test was used. The Z test or Barnard exact test (n< 5 in any field) were used for comparisons of categorical data. A two-sided p< 0.05 was considered statistically significant for the primary outcome. Results: Of the 178 consecutive primary TKA cases performed in one year, 133 were removed according to inclusion and exclusion criteria, leaving 45 cases (21 femoral; 24 adductor canal) for analysis. Morphometric and procedural details were similar between groups (Table 1). For the primary outcome of maximum ambulation distance, patients in the adductor group walked a median (10th90th percentiles) of 24 (0-60) meters vs. 6 (0-24) meters in the femoral catheter group (p=0.023). A post-hoc power calculation revealed 89% power to detect this difference. Adductor canal patients ambulated further than femoral catheter patients at 3 of 4 physical therapy time points (Figure 1). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups. [Figure 1] Conclusion: Continuous adductor canal blocks may allow patients to ambulate further than femoral nerve blocks in the early postoperative period following TKA within an established clinical pathway without reduction in analgesia. Confirmation of these findings through prospective study is warranted. References: 1) Pain 2010;150:477-84; 2) Anesth Analg 2010;111:1552-4; 3) Anesthesiology 2013;2:409-15; 4) Acta Anaesthesiol Scand 2012;56:357-64. A58 THE IMPACT OF SELECTION CRITERIA FOR BILATERAL KNEE ARTHROPLASTIES ON PERIOPERATIVE OUTCOMES 1 1 1,2 1 1 S.G. Memtsoudis , L.A. Poultsides , O. Stundner , H. Do , M. Figgie , T.P. Sculco 1 1 2 Department of Anesthesiology, Department of Orthopedic Surgery, Hospital for Special Surgery, 3 Weill Medical College of Cornell University, New York, NY, USA, Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, 4 Austria, Department of Epidemiology and Biostatistics, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA Introduction: Bilateral total knee arthroplasty (BTKA) procedures are associated with increased morbidity and mortality, compared to unilateral approaches [1]. In an attempt to reduce this risk and improve perioperative outcomes of patients undergoing this procedure, our institution has implemented selection criteria in 2006 in order to select younger and healthier patients for BTKA (age < 75 years, ASA I-II, absence of any major cardio-pulmonary morbidity) [2]. To date, however, the effectiveness of such a strategy has not been evaluated. Therefore, we aimed at analyzing the impact of the introduction of these guidelines on perioperative outcome. Material and methods: All BTKAs performed consecutively at our institution between 1998 and 2011 were reviewed and included into the analysis. Patients were grouped according to date of surgery: (a) before (1998-2005) and (b) after (2006-2011) introduction of the guidelines. Groups were compared in terms of demographics, comorbidity burden and incidence of major perioperative complications. Poisson regression was performed to obtain rate-ratios and proportional changes in complication rate, adjusted for length of stay. Results: The number of BTKA procedures performed at our institution was 1,968 before implementation of the guidelines (1998-2005), and 1,992 afterwards (2006-2011). Patients in the group before the introduction of selection criteria were older (65.8 years (SD 9.5) vs. 64.2 years (SD 8.5); p< 0.0001) and had a higher average comorbidity burden (Deyo-Index 0.38 (SD 0.9) vs 0.30 (SD 0.7); p=0.001). After introduction of the guidelines, the prevalence of cardiac and pulmonary comorbid disease decreased, however, only the reduction in cardiac disease was statistically significant (coronary artery disease: 8.2% vs 5.8%, p=0.0036; congestive heart failure: 1.5% vs 0.5%, p=0.0006). The incidence of major complications decreased from 7.6% to 5.4% (p=0.0135). Major constituents of this decrease were, specifically, reductions in the incidence of myocardial infarction (0.6% vs 0.1%, p=0.0117) and other cardiac complications (2.8% vs 0.6%, p< 0.0001), whereas the incidence of pneumonia and pulmonary embolism remained similar before and after the implementation of guidelines. After 2006, the overall rate of major morbidity and mortality decreased significantly, by 9% per year on average. The rate-ratio (RR) for combined complications comparing post- vs. pre-intervention was RR=0.87 (CI 0.78;0.97; p=0.0141) indicating a significantly lower rate of major complications after implementation of the guidelines. Although we saw decreases in rate-ratios for individual cardio-pulmonary complications, only that for pulmonary embolism reached statistical significance (RR=0.67 (CI 0.51;0.89; p=0.0049). Discussion: After implementation of selection criteria for BTKA candidates at our institution, a reduction in average age and comorbidity burden was accompanied by a reduction in incidence and rates ratios of major morbidity and mortality. Although a causal relationship cannot be determined using our dataset, and although other unmeasured variables may have contributed to this trend, our results suggest that introduction of such guidelines can be associated with a reduction in perioperative adverse outcomes. A59 THE MAXIMUM EFFECTIVE NEEDLE-TO-NERVE DISTANCE FOR ULTRASOUND-GUIDED INTERSCALENE BLOCK E. Albrecht, K. Kirkham, R.V.W. Endersby, C. Tse, V.W.S. Chan, R. Brull University of Toronto, Toronto, ON, Canada Introduction: Direct needle trauma and intraneural injection are important mechanisms of nerve injury associated with regional anesthesia. Despite ultrasound (US) guidance, unintentional 1 intraneural needle tip placement is common, especially during interscalene block (ISB). While 2 needle-to-nerve proximity is the fundamental requisite for a successful block, the maximum effective distance between the needle tip and the target nerve is unknown. This study aimed to determine the maximum distance the needle tip can be placed from the roots of the interscalene brachial plexus while still achieving a successful block for shoulder surgery. Material and methods: Twenty adult patients scheduled for ambulatory arthroscopic or open shoulder surgery received an US-guided ISB using 20 mL of bupivacaine 0.5% with epinephrine. The first block was performed with the needle tip positioned outside but in contact with the brachial plexus sheath, at a location equidistant between C5-C6. For subsequent blocks, the Dixon up-and-down method was followed: the distance from needle tip to sheath was increased or decreased by 2 mm for each consecutive patient according to the block success or failure respectively, in the previous patient. A successful block was defined as complete motor and sensory block in the C5 and C6 territories at 30 minutes. All patients received a general anesthetic. The primary outcome was the maximum effective distance required to achieve a successful block in 50% (MED50) of patients. Secondary outcomes included intraoperative and postoperative (Phase I recovery) fentanyl consumption, pain scores upon arrival in Phase 1 recovery (numeric rating scale [NRS] out of 10), duration of motor and sensory blockade, time to first dose of oral opioid analgesic at home, and complications. Results: The MED50 was 8.0 mm (95%CI: 6.0-10 mm). Figure 1 depicts the sequence of successful and unsuccessful ISBs. Among the 11 patients with a successful ISB, the median intraoperative and postoperative fentanyl consumption was 150 µg (Interquartile Range [IQR] 150-175 µg) and 75 µg (IQR 25-75 µg), respectively. The median NRS pain score in Phase I recovery was 2 (IQR 0-3). Median durations of motor and sensory blockade were 19.8 hours (h) (IQR 15.0-22.3 h) and 10.1 h (IQR 8.5-12.2 h), respectively. The time to first dose of oral opioid analgesic at home was 9.6 h (IQR 9.3-12.1 h). No complications were reported. [Up-and-down sequences of ISB for the MED50] Discussion: A successful ISB can be achieved with a distance of 8 mm between the needle tip and the brachial plexus sheath in 50% of patients. Our results suggest that it may not be necessary to position the needle tip as close as possible to the nerve roots during US-guided ISB. Future studies are required to explore the concept of maximum effective needle-to-nerve distance for other types of peripheral nerve blocks with a view towards enhancing safety. References: 1. Orebaugh SL et al. Subepineurial injection in ultrasound-guided interscalene needle tip placement. Reg Anesth Pain Med.2010;35:450-454. 2. Moore DC. "No paresthesias-no Anesth.1997;22:388-390. anesthesia," the Funding and interest disclosure: Nothing to disclose. nerve stimulator or neither? Reg A60 THE IMPACT OF THE COMMON INVESTING EXTRA NEURAL LAYER ON MINIMUM STIMULATION THRESHOLD CURRENT DURING ULTRASOUND-GUIDED SUBGLUTEAL SCIATIC NERVE BLOCK J. Buren, A. Brodskaia, M. Kendall, A. Nader Feinberg School of Medicine Department of Anesthesiology, Northwestern University, Chicago, IL, USA Introduction: The two components of the sciatic nerve are enclosed by a dense connective tissue that forms a common investing extraneural layer (CIEL) that extends along the trajectory of the sciatic 1 nerve. The minimum threshold current (MTC) that elicits a desired evoked motor response (EMR) is frequently sought for sciatic nerve localization. MTCs ranging from 0.14 to 0.46 mA have been 2-5 reported in studies evaluating sciatic nerve analgesia. A previous study demonstrated thresholds down to 0.3 mA at a pulse width of 100 µsec are required to achieve a success rate of 95% in patients 6 without polyneuropathy. We evaluated the relation between the needle tip and MTC required to elicit an evoked motor response with the needle tip external and internal to the CIEL of the sciatic nerve. Methods: After IRB approval, 139 patients undergoing knee replacement were recruited to participate. A 21 g echogenic stimulating needle connected to the negative lead of the nerve stimulator was directed toward the sciatic nerve using a subgluteal approach. The needle tip was directed toward the medial component of the sciatic nerve under ultrasound visualization until indentation of the CIEL was visualized and the MTC recorded. The needle was then advanced between the components of the sciatic nerve, and the MTC was recorded. Patients were followed until the resolution of the block and were contacted by phone at 2 weeks and at one month to evaluate neurological symptoms. All patients were examined for neurological deficits at one month following surgery using a calibrated filament. Minimum threshold currents were compared using a paired t-test. Cumulative probabilities densities for above and below the CIEL minimal thresholds were calculated (Figure 1). Results: The mean MTC for above the CIEL stimulation was 0.52 ± 0.15 mA (95% CI 0.49-0.54) compared to 0.19 ± 0.09 mA (95% CI 0.18-0.21) below the CIEL. The mean difference from above to below was 0.32 ± 16 mA (95% CI 0.28-0.35). The lower 5% interval of the MTC outside the CIEL was between 0.18-0.31 mA. The upper 5% interval of the MTC below the CIEL was between 0.33-0.44. The highest mA recorded below the CIEL was 0.44mA while the lowest mA achieved outside the CIEL was 0.18mA. [Figure 1] Discussion: Traversing the CIEL of the sciatic nerve substantially decreased the MTC needed to obtain an EMR, suggesting that low MTC (< 0.31mA) is likely associated with 95% confidence that needle positioning is below the common investing extraneural layer of the sciatic nerve in the subgluteal region. References: 1. Reg Anesth Pain Med 2012;37:363-5 2. Anesth Analg. 2004;99(2):584-8. 3. Anesthesiology. 2011;115(3):596-603. 4. Anesth Analg. 2009;108(1):359-63 5. Anesth Analg. 2010;110(3):951-7. 6. Anaesthesist. 2001 Mar;50(3):181-6. A61 FORCE REQUIRED FOR DISPLACEMENT OF UNTUNNELED, TUNNELED AND DOUBLE TUNNELED PERIPHERAL NERVE CATHETERS K. Byrne, V. Freeman Anaesthesia Department, Waikato Hospital, Hamilton, New Zealand Introduction: There are no studies which objectively measure whether tunneling increases the force required to displace a peripheral nerve catheter. This study aims to objectively measure the force required to displace untunneled and tunneled catheters by 1cm, and introduces another technique, double tunneling a catheter to further reduce the risk of catheter displacement. Methods: Four freshly butchered pork shoulders were obtained from a local butchery. They were o stored at room temperature (20 C) until all had reached a uniform temperature, and the experiments were conducted at room temperature. B.Braun contiplex catheter kits were used for all trials containing 18G Tuohy needle and a 20G catheter. 1 A pre-experiment sample size calculation using variance from a previously conducted experiment , and an arbitrarily decided effect size of a 50% change in the force of displacement being clinically significant, the number of trials needed to show a statistically significant difference between the groups calculated at 13. The 18G Tuohy needles were inserted to depth of 5cm at an angle of 45 degrees to the tissue surface. The catheters were then fed to a distance of 8 cm at the skin and the needle then removed without withdrawing the catheter. Subcutaneous tunnels were then formed for the tunneled and double-tunneled groups by inserting the Tuohy needle subcutaneously inline with the exit point of the catheter and the catheter fed retrogradely through the Tuohy needle. A portable electronic scale (Wei-Heng WH-A05) with resolution of 5g was used to determine the force used to dislodge the catheter by one cm was then attached to the end of the catheter by feeding the catheter through a three way tap attached to a loop of tubing that was then attached to the hook on the end of the scale. Results: A 3 way anova comparison of the groups showed a highly significant (p < 0.0001) difference between the 3 groups in the force required for displacement of the catheter by 1cm. The double tunneled catheters required the most force to displace, the single tunnel the next most force to displace, and the untunneled catheters required the least force to displace. Discussion: This study shows a significant difference in the displacement force required for peripheral nerve catheters in a porcine model when the catheter is either untunneled, tunneled or double tunneled. This seems to indicate that the simple act of tunneling the catheter should be recommended for all continuous nerve blockade techniques. Double tunneling is a new technique which does not seem to be have been described in the literature previously. In this study catheters that were double tunneled were associated with nearly a four fold increase in force required for displacement compared to single tunneled catheters, and a 17 fold increase in force of displacement compared to untunneled catheters. References: 1. Tsui BC, Tsui J. Less leakage and dislodgement with a catheter-over-needle versus a catheter-through-needle approach for peripheral nerve block: an ex vivo study. Can J Anaesth 2012;59:655-661. Funding: B.Braun provided all the catheter kits free of charge A62 VARIABILITY IN ANESTHETIC CARE FOR TOTAL KNEE ARTHROPLASTY IN THE UNITED STATES 1 1 1 1 1 2 P. Fleischut , L. Gaber-Baylis , R. Rasul , S. Faggiani , M. Mazumdar , R. Dutton , S. Memtsoudis 1 1 2 Anesthesiology, New York-Presbyterian Hospital, Weill Medical College of Cornell University, Public 3 Health, Weill Medical College of Cornell University, New York, NY, Anesthesia Quality Institute, Park 4 Ridge, IL, Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA Background: With a volume of over 700,000 procedures performed annually, total knee arthroplasties are one of the most commonly performed orthopedic inpatient surgeries in the US. However, little is known about the utilization and related characteristics of various anesthetic practices in the United States. Therefore, we sought to characterize anesthesia practice patterns utilizing the largest national anesthesia database provided by the Anesthesia Quality Institute (AQI). Methods: We utilized data collected by the AQI between 2010 and 2012 and identified all primary total knee arthroplasties. The proportion of cases performed primarily under general, neuraxial or regional anesthesia was determined. The average anesthesia times for each type were determined. The utilization of the various types of anesthesia was further analyzed by anesthesia provider model (solo anesthesiologist, anesthesiologist working with resident or anesthesiologist working with CRNA), by anesthesiologist's board certification status, by patient characteristics (age, gender, ASA physical status) and by facility type (University hospital, large/medium/small community hospital). Chi-squared test was used to determine differences between groups for categorical variables. For continuous variables, means and ANOVA tests were analyzed to compare groups. A P-value of < 0.05 was considered to indicate a significant difference between groups. Results: We identified a total of 95,176 cases of total knee arthroplasty of which 81% had available information on the primary anesthesia type used. Of those 53%, 36% and 10% were performed under general, neuraxial or regional anesthesia respectively. Average anesthesia times were 149, 141 and 137 minutes, respectively (P < 0.0001). Patients undergoing general anesthesia were on average younger (64.3, 67.0, and 67.6 years (P < 0.0001). Gender distribution among groups was similar (female 59%, 63%, and 60%, P < 0.0001). The proportion of patients with an ASA class of 3 and higher was highest in the regional anesthesia group (38%, 38%, 46% (P < 0.0001). A resident was more commonly part of the anesthesia care team when neuraxial anesthesia (9%) compared to general (5%) was used. The opposite was true for CRNA involvement (45% vs. 41%, (P < 0.0001). When regional was the primary type of anesthesia, residents were involved in 3% and CRNAs 52% of the time. When a neuraxial or regional technique was used as the primary type of anesthesia, the anesthesiologist was more frequently board certified than when a general anesthetic was provided (79%, 72% and 54%, respectively (P< 0.0001). The majority of cases (>94%) were performed in community hospitals. Proportionally, most procedures under general and neuraxial anesthesia were performed in medium-sized community hospitals (60% and 71%), while the biggest proportion of primarily regional anesthesia cases took place in large community hospitals (47%). The utilization of general, neuraxial and regional as a proportion of individual practices varied significantly (14%-100%, 0%-86%, and 0%-84% (P < 0.0001). Conclusion: After preliminary analysis, considerable variation of the utilization of anesthetic techniques was found for the performance of total knee arthroplasty among AQI participating practices. Variability was further seen related to patient and anesthesia provider characteristics. Reasons for these finding remain unclear and analysis is ongoing. A63 EFFECTS OF STEROIDS ON THROMBOGENIC MARKERS IN PATIENTS UNDERGOING UNILATERAL TOTAL KNEE SURGERY K. Jules-Elysee, T. Sculco, J. Beathe, J.T. YaDeau, V.L. Buschiazzo, A. McLawhorn, E. Purdue, Y. Ma 1 Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 3 Orthopedics, Hospital for Special Surgery, Orthopedics, Weill Medical College of Cornell University, 4 5 Research Division, Epidemiology and Biostatistics, Hospital for Special Surgery, New York, NY, USA 2 Introduction: In spite of thromboprophylaxis therapy, deep vein thrombosis (DVT) and pulmonary embolism (PE) still remain important complications in patients undergoing total knee arthroplasty (TKA).Systemic thrombin generation starts in the early peri-operative period as demonstrated by a rise in thrombogenic markers 4 hours post-surgery. Inflammation characterized by a rise in IL6 with surgery is thought to play a major role in the initiation of coagulation pathway via expression of tissue factor. In addition low dose steroids have been shown to stimulate tissue plasminogen activation leading to fibrinolysis. In this study, we assessed the effect of steroids on the release of thrombogenic markers, plasmin antiplasmin (PAP), a marker of fibrinolysis and prothrombin fragment (PF 1.2) a marker of trombin generation. Methods: This triple blinded placebo controlled study was approved by hospital IRB. The study group received 100 mg of intravenous hydrocortisone 2 hours prior to surgery, followed by an additional 2 doses, each 8 hours post-op. The control group received normal saline at each time point. Blood samples were taken pre-incision and at 4 hours post tourniquet (TQ) release. Blood was centrifuged at 3500 rpm, and the supernatant examined. The samples were subsequently assayed for PAP and PF 1.2. Results: A total of 24 patients undergoing unilateral TKA were included in the study (13 in the placebo group, 11 in the study group). The change in PF 1.2 between baseline and 4 hours post TQ in the control group was significantly greater compared to the study group (674+/- 260 vs. 349+/- 332; p-value 0.01) In addition, the study group had significantly lower PF 1.2 at 4 hours compared to the control group (615 +/- 357 vs. 937+/- 317; p-value 0.04). Although PAP was higher in the study group at 4 hours, 1638 +/- 823 vs. 1206 +/- 624, it did not reach statistical significance (P=0.18). Conclusion: This dose regimen of steroids significantly decreased the amount of thrombin generation seen with TKA without interfering with fibrinolysis. The mechanism is most likely due to decreased inflammation from reduced IL6 levels. This may have major clinical implications in terms of post-op DVT or PE. Clinical studies are needed for further evaluation. References: 1. Reikeras et al. Thrombosis markers in hip versus knee arthroplasty: a pilot study Journal of Orthopaedic Surgery 2009; 17(3):291-5. 2. Jules et al. Use of low-dose steroids in decreasing cytokine release during bilateral total knee replacement. RAPM. 2011 Jan-Feb; 36 (1):36-40. N Age Avg. TQ time Avg. Blood loss Avg. PF 1.2 4hrs post-op (pMol/L) PAP 4hrs post-op (mcg/L) Placebo 13 66.6 46 213 937 ± 317 1206 ± 624 Treatment 11 68 44 206.2 615 ± 357 1638 ± 823 0.04 0.18 P-Value [Unilateral Patients] A64 ULTRASOUND-GUIDED TRANSVERSUS ABDOMINUS PLANE (TAP) BLOCK FOR LAPAROSCOPIC GASTRIC-BYPASS SURGERY: A PROSPECTIVE RANDOMIZED CONTROLLED DOUBLE-BLINDED TRIAL K.R. Kirkham, E. Albrecht, R.V.W. Endersby, V.W.S. Chan, T. Jackson, A. Okrainec, T. Penner, R. Jin, S. Abbas, R. Brull 1 2 Anesthesia and Pain Management, UHN - Toronto Western Hospital, Anesthesia, University of 3 Toronto, Surgery, UHN - Toronto Western Hospital, Toronto, ON, Canada Introduction: Despite the laparoscopic approach, patients can suffer moderate to severe pain 1 following bariatric surgery. The transversus abdominis plane (TAP) block has been demonstrated to 2 3 improve pain-related outcomes after both laparoscopic and open abdominal procedures. This randomized controlled double-blinded trial investigated the analgesic efficacy of ultrasound-guided TAP blocks for laparoscopic gastric-bypass surgery (LGBS). Materials and methods: Seventy patients undergoing LGBS were randomized to receive either bilateral ultrasound-guided subcostal TAP block injections after induction of general anesthesia or none. All patients received trochar insertion site local anesthetic infiltration and systemic analgesia. The primary outcome was cumulative opioid consumption (IV morphine equivalent) during the first 24 hours postoperatively. Interval opioid consumption, pain severity scores, and rates of nausea or vomiting were measured during Phase I recovery, and at 24 and 48 hours postoperatively. Results: There was no difference in cumulative opioid consumption during the first 24 hours postoperatively between the TAP (31.6 mg [95%CI: 26.9 - 36.4]) and control (34.2 mg [95%CI: 27.7 40.5]; P=0.52) groups. However, opioid consumption during Phase I recovery was significantly less in the TAP (13.5 mg [95%CI: 11.2 - 15.9]) compared to the control (17.2 mg [95%CI: 14.4 - 20.0]; P=0.04) group. Postoperative opioid consumption during the 24-48 hour interval was similar between groups, as were pain scores at rest and with movement during all measured intervals. The rate of nausea or vomiting was less during Phase I recovery in the TAP (13.8%) compared to the control (38.2%; P=0.04) group with no measurable differences during any interval thereafter. There were no complications related to any of the block procedures. Discussion: Bilateral TAP blocks performed prior to surgical incision do not provide additional analgesic benefit beyond Phase I recovery when added to trochar insertion site local anesthetic infiltration and systemic analgesia for laparoscopic gastric-bypass surgery. References: 1. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg. 2008;106:1741-1748. 2. El-Dawlatly AA, Turkistani A, Kettner SC, et al. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 2009;102:763-767. 3. Ra YS, Kim CH, Lee GY, Han JI. The analgesic effect of the ultrasound-guided transverse abdominis plane block after laparoscopic cholecystectomy. Korean J Anesthesiol. 2010;58:362-368. Funding: Dr. Richard Brull is supported by the Merit Award Program, Department of Anesthesia, University of Toronto. Personal Conflicts of Interest Disclosure: Nothing to disclose. A65 IS THERE A DOSAGE EFFECT OF DEXAMETHASONE AS AN ADJUVANT FOR BRACHIAL PLEXUS NERVE BLOCK? - A PROSPECTIVE RANDOMIZED DOUBLE-BLINDED CLINICAL STUDY J. Liu, K.A. Richman, N. Elkassabany Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, PA, USA Introduction: Brachial plexus block is a great option for postoperative pain management after shoulder arthroscopy. Dexamethasone, as an adjuvant, to local anesthetics further expanded our capability to provide longer duration of analgesia with a single shot nerve block. Recent evidence showed that that 8mg of preservative-free dexamethasone has been able to prolong the analgesia duration of brachial plexus nerve block by 50 to 100 percent. There is only one study with reduced dosage of dexamethasone of 4mg by Dr. Nader´s group. The authors observed decreased analgesia duration from 25.2 to 21.6 hours, while not statistic significant. The safety of adding dexamethasone and the implication to the incidence of neuronal damage are still in question. Available studies failed to draw any definitive conclusion about the safety of adding dexamethasone because of the limited number of the studies and the small sample size in each. It is appealing that lower dose of dexamethasone may be clinically effective with decreased risks. We hypothesize that dexamethasone as an adjuvant to local anesthetic has dose response effects in regards to the duration of sensory and motor nerve blocks. Methods: The study was reviewed and approved by the institutional review board of the University of Pennsylvania. We proposed to recruit 100 outpatient patients undergoing shoulder arthroscopic surgery between the age of 18 to 70 with ASA I-III physical status. All patients will receive general anesthesia and an ultrasound guided supraclavicular brachial plexus nerve block with 30ml of 0.25% bupivacaine. All patients will be randomly assigned into one of four groups: control group, 1mg dexamethasone, 2mg dexamethasone, or 4mg dexamethasone in addition to 0.25% bupivacaine. All patients will be interviewed over the phone on post-operative day 1, day 2, and day 7. The recovery of sensory, motor, time to first opioid requirement, and opioid consumptions will be recorded. All data will be analyzed via ANOVA. Results: Currently, we have recruited over 40 patients into the study. Preliminary data analysis showed that duration of analgesia was significantly prolonged in all groups received dexamethasone. The average analgesia duration of plain 0.25% bupivacaine was 15.7 hours, while average analgesia durations were 22.4, 23.4, and 22.2 hours for dexamethasone 1mg, 2mg, or 4mg group respectively. The average durations of motor block showed similar trend. Discussion: Our preliminary data analysis showed no dose response effect of dexamethasone as an adjuvant to local anesthetic for brachial plexus nerve block. The addition of dexamethasone to bupivacaine significantly prolonged the duration of sensory and motor nerve block. In addition, our preliminary finding indicated shorter motor block duration than sensory block. We are currently actively recruiting additional patients into this study. A66 COMPARATIVE STUDY OF GENERAL ANESTHESIA VERSUS LOCAL ANESTHESIA FOR CAROTID ENDARTERECTOMY H. Martinez-Wilson, J. Liu Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, PA, USA Background: Carotid endarterectomy (CEA) is an effective tool in reducing stroke risk in selective patient groups. The ideal anesthetic technique remains controversial in light of available literature, which has shown no difference in postoperative mortality between general anesthesia (GA) and local anesthesia (LA) for CEA. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a nationally validated, risk-adjusted, outcome-based program used to measure surgical outcomes. A retrospective study of the NSQIP database between 2005 and 2009 looking at the composite risks of stroke, myocardial infarction, and death did not show significant patient 1 outcome differences between GA and LA groups (2.8% versus 3.6%) undergoing CEA . However, no detailed information on each individual risk was reported. With this in mind we set to investigate the individual complications on the nervous and cardiovascular systems during LA or GA for CEA. We hypothesized that LA is associated with lower 30-day post-operative cardiac risk, including cardiac arrest and myocardial infarction. Methods: We studied the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010. There were total of 34353 patients included in our final cohort, with 28969 patients receiving general anesthesia and 5384 patients receiving local, regional anesthesia, or monitored anesthesia care (LRA). The outcome measurements of 30 days postoperative complications included stroke, coma, cardiac arrest, myocardial infarction, and death. Results: The overall mortality was 0.76% and 0.76% between LRA and GA subjects respectively (P=0.932). There were no differences in regards to stroke (1.45% versus 1.57%), coma (0.09% versus 0.08%), and cardiac arrest occurrence (0.22% versus 0.30%). However, LRA group had significant lower risk of myocardial infarction risk (0.32% vs. 0.74%, P< 0.001). Conclusions: This study suggests that, in comparison to GA, patients receiving local, MAC, and/or regional anesthesia had a significant lower risk of postoperative MI. Though this study is limited by the data available through the NSQIP database, it should serve as a framework to build a more comprehensive study looking at post operative MI in patients receiving GA versus local, MAC, and/or regional anesthesia. Reference: 1. Schechter MA, Shortell CK, Scarborough JE. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery. 2012 Sep;152(3):309-14 A67 A RANDOMISED COMPARISON OF COMBINED SUPRASCAPULAR AND AXILLARY (CIRCUMFLEX) NERVE BLOCK WITH INTERSCALENE BLOCK FOR POSTOPERATIVE ANALGESIA FOLLOWING ARTHROSCOPIC SHOULDER SURGERY D. Price, A. Abeysekera, M. Chaddock North Shore Hospital, Auckland, New Zealand Introduction: Interscalene block (ISB) is the gold standard technique for analgesia following shoulder surgery. However it is associated with a high frequency of well-known side effects, and has the potential to result in serious complications. The aim of this randomised controlled study was to determine whether an alternative technique, combined suprascapular and axillary (circumflex) nerve block (CSANB), could provide analgesia comparable to ISB, with a reduction in the rate of side effects and complications. Methods: 106 consecutive patients undergoing minor arthroscopic shoulder surgery were randomised. In Group ISB, 30ml of 0.75% ropivacaine was injected on location of the C5,6 roots. In Group CSANB, 15ml of 0.75% ropivacaine was injected in the vicinity of each nerve using the 1 combined Meier-Price technique . All patients underwent general anaesthesia as per protocol. CSANB also received 3 to 6mg of morphine intraoperatively, on a per weight basis. Results: Area under the curve of numerical rating pain scores (NRPS) recorded on emergence and at 1, 2, 6 and 24 hours postoperatively, showed no statistical difference between groups at rest. Movement NRPS were statistically higher in CSANB. The NRPS vs time curve profile differed between groups, with higher pain scores up to 6hrs for CSANB, and at 24hrs for ISB. Opiate consumption mirrored pain scores: CSANB consumed higher levels of intravenous morphine in first 2 hrs, but reported lower oral oxycodone requirements between 6 and 24hrs (Table 1). ISB were more likely to report the time at which the block receded and pain intensified (Table 1). CSANB patients were less likely to describe a dislike of side effects, and their reduction in peak expiratory flow rate postoperatively was less significant Conclusion: ISB provides superior analgesia in the first 2 hrs postoperatively, but at the cost of more significant side effects. From 6hr to 24hr, pain relief appears superior with CSANB. References: 1. Price DJ. The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesthesia Intensive Care 2007;35:575-581 Funding disclosure: This project was funded by an Australia and New Zealand College of Anaesthetist Novice Research Grant, awarded in 2009. There are no conflict of interest disclosures to make. [Table 1] [Table 2] A68 ANATOMICAL RELATIONSHIP OF THE POPLITEAL ARTERY AND SCIATIC AND TIBIAL NERVES: RELEVANCE TO POPLITEAL SCIATIC NERVE BLOCK G. Woodworth, J. Trujillo, E. Foss, M. Semenza II 1 2 Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA Introduction: Ultrasound-guided sciatic nerve block in the popliteal fossa is a common regional anesthetic approach for distal lower extremity surgery. (1, 2) Due to occasional difficulties in locating the sciatic nerve, one technique is to identify the popliteal artery in the popliteal fossa and use it as a landmark to identify the tibial nerve. The nerve can then be traced back to its bifurcation from the sciatic nerve. (3, 4) Prior studies have demonstrated the anatomical variability of the bifurcation of the sciatic nerve in the posterior knee and thigh, and the variability of the popliteal artery in the popliteal fossa; however, to our knowledge, no published studies have directly examined the variability of the sciatic nerve to the popliteal artery. In this study we examined the anatomical relationship of the popliteal artery and the tibial or sciatic nerve at three different locations in the popliteal fossa. Methods: Axial MRI scans of the knee for 100 subjects were examined. The angle and distance from the popliteal artery to the target nerve was recorded at measurement points 0, 5, and 8 cm proximal to the distal femur. The mean distance and angle between the popliteal artery and tibial nerve was calculated. The distances and angles were correlated with BMI. Results: At the distal femur the tibial nerve is within a few millimeters of the popliteal artery. (Table 1) Although in all cases the nerve was posterior to the artery, the nerve was variably distributed medial and lateral to the artery. (Figure 1) At 5 cm proximal to the distal femur, the nerve was always posterior to the artery and in greater than 95% of cases posterolateral to the artery at a mean distance of 9.9 mm. At 8 cm proximal to the femur, the nerve was always posterior to the artery and in greater than 95% of cases posterolateral to the artery at a mean distance of 16.1 mm. BMI was significantly correlated with the distance between the artery and the nerve with the effect strongest at 8 cm proximal to the distal femur. Figure 1 is a scatter plot detailing the location of the tibial/sciatic nerve in relation to the popliteal artery. Plot A, B and C represent 0, 5 and 8 cm proximal to distal femur. The 0/0 location identifies the popliteal artery. Distance proximal from distal femur 0 cm 5 cm 8 cm Mean distance from nerve to poplital artery in mm (SD) 2.8 (1.9) 9.9 (4) 16.1 (5.2) Mean angle from nerve to popliteal artery in degrees (SD) 21 (21) -31 (15) -44 (16) [Distance and Angle of Nerve to Popliteal Artery] [Figure 1] Discussion: The data from this study provide valuable information when using the popliteal artery as an anatomic landmark to identify the tibial/sciatic nerve. At 5 cm proximal to the distal femur the popliteal artery can reliably be used as an anatomic landmark to locate the tibial/sciatic nerve due to the close proximity and consistent location of the nerve posterolateral to the artery. References: 1) Anesthesiology 2006;104:309-314. 2) RAPM 2008;33:369-376. 3) RAPM 2006;31:481-482. 4) RAPM 2008;33:281-282. A69 APPROACHES TO TOTAL KNEE ARTHROPLASTY AT UNC: MULTIMODAL REGIONAL ANESTHETICS VERSUS MONOMODAL GENERAL ANESTHETICS B. Sumrow, A. Powell, M.Y. Qadri, A. Bortsov, R. Coombs 1 2 University of North Carolina, Department of Anesthesiology, UNC Hospitals, Chapel Hill, NC, USA Background: Traditionally total joint arthroplasty was performed under general endotracheal anesthesia (GETA). This approach has been abandoned by many surgeons in favor of neuraxial/regional approaches. Proponents of this shift cite improved pain control, decreased perioperative complications, and shorter hospital stays. At UNC Hospitals there remains a dichotomy between the approaches to total knee arthroplasty (TKA) based on surgeon preference. This study aims to compare patient outcomes between those who receive a structured, regional-based, multimodal-analgesic approach versus the outcomes of patients who receive a general anesthetic. Methods: Medical records of each patient at UNC Hospitals receiving a TKA between 9/2011 and 5/2012 were identified. Using PACU nursing notes, CPA documentation, and discharge summaries, the following retrospective data was recorded: performing surgeon, use of GETA, age/gender, intraoperative opioid totals (morphine equivalents), PACU opioids received, PACU pain scores, PACU length-of-stay, days to hospital discharge, presence of postoperative peripheral nerve block (PONB), and presence of postoperative epidural (POE). Distributions of the outcome measures were explored using standard statistics (mean, median, standard error, range), comparing the two approaches as well as patients receiving general anesthetics versus those that did not. Differences between groups were assessed with the Student t-test. Multivariate regression was used to identify independent predictors of the outcomes. P-values < 0.05 were considered statistically significant. Results: A total of 94 cases were examined. Nineteen cases were performed under GETA and 71 were performed primarily with a regional/neuraxial technique. Of the 94 cases, 10 required PONB and 10 required POE, with two patients requiring both PONB and POEs. Ketamine was used in 29/94 cases. Comparing GETA vs Non-GETA, significant differences were found between intraop and total opioid use, PACU pain scores, and days to discharge. Patients undergoing GETA received more intraoperative opioid (34.1 ± 3.2 vs 13.2 ± 1.7 MEs, mean ± SE, p < 0.0001) and total opioid during their stay (49.8 ± 6.3 vs 20.5 ± 3.3, p < 0.0001). GETA patients also had higher pain scores on arrival to the PACU (4.4 ± 0.8 vs 2.0 ± 0.4 on a scale from 0 - 10, p = 0.011) and higher maximum pain scores during their PACU stay (6.3 ± 0.9 vs 3.8 ± 0.5, p = 0.013). In our cohort, no significant differences were found in the length of stay in the PACU between individuals undergoing GETA or regional techniques (135.8 ± 21.9 vs 142.5 ± 11.2 minutes, p = 0.781). However, there was a significant difference between days-to-discharge between the two groups, with those undergoing GETA staying significantly longer than those undergoing regional anesthesia (5.05 ± 0.4 vs 3.2 ± 0.2 days, p < 0.0001). Conclusions: This study demonstrates that a regional anesthetic approach decreases intraoperative and postoperative opioid requirements, postoperative pain scores in the PACU, and days to discharge. PACU length of stays were not dependent upon anesthetic technique, despite these other significant decreases seen with the use of regional anesthesia techniques. Future work may involve larger cohorts, more surgeons, and a more structured regional technique. A70 THE SUCCESS AND DURATION OF SCIATIC NERVE BLOCK USING 0.5% BUPIVACAINE OR ROPIVACAINE AT DIFFERENT VOLUMES: A DOUBLE BLIND RANDOMIZED CLINICAL TRIAL D. Szczodry, M.C. Kendall, R.J. McCarthy, A. Nader Anesthesiolgy, Northwestern University, Chicago, IL, USA Introduction: Sciatic nerve contains a tibial and peroneal component surrounded by common 1 investing extraneural layer (CIEL). Traditional nerve stimulator guided technique requires large 2 volume of local anesthetic (LA) to perform successful sciatic nerve block (SNB). This prospective double blind randomized study was designed to determine the effect of wide range of volumes of LA injected beneath the CIEL on the onset, success and duration of SNB. Material and methods: After IRB approval, 139 adult patients scheduled for total knee arthroplasty consented to participate. All subjects received an ultrasound-guided nerve stimulator assisted SNB using the infragluteal-parabiceps approach. Subjects were randomized into 14 groups to receive 0.5% bupivacaine or 0.5% ropivacaine with epinephrine 1:300,000 in volumes ranging from 2.5ml to 30ml (12.5mg- 150mg). An evoked motor response of plantar flexion or inversion was sought. Following LA injection, sensory and motor assessments (3-point scale) were performed by a blinded investigator every 2 min for 10 min and at 5min intervals until 60 min prior to surgery. Motor and sensory block were assed every 4hrs until complete SNB resolution. Successful block was defined as a complete pinprick sensory and motor block at 60min in the distribution of the sural, tibial, deep and superficial peroneal nerves. The duration of sensory and motor block were recorded. Results: 139 subjects completed the study. There was no difference in patient characteristic between groups. Injection volume of 2.5 and 5ml were associated with delayed onset and a dose dependent decrease in block duration and a greater fraction of subjects experiencing pain behind the knee in the ropivacaine group. Injection volumes ≥10ml produced complete block within 30min. [Figure 1] Conclusions: Injecting 10 ml of 0.5% bupivacaine or 0.5% ropivacaine below CIEL produces duration of sensory and motor blockade as volumes as large as 30ml. References: 1. Reg Anesth Pain Med. 2012; 37:363-5. 2. Anesth Analg 2006; 102:593-7. A71 USE OF ADDUCTOR CANAL COMPARTMENT BLOCKADE FOR TOTAL KNEE ARTHROPLASTY: RESULTS OF OUR INSTITUTIONAL OBSERVATIONAL STUDY A. Vydyanathan, M.V. Tu, R. Maret, B. Kosharskyy, K. Gritsenko, N. Shaparin Anesthesiology and Pain Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, New York, NY, USA Introduction: The use of regional anesthesia following total knee replacement has revolutionized postoperative pain control and facilitated rehabilitation (1). Femoral nerve blockade has been traditionally used for this surgery, but one concerning issue is the incidence of quadriceps weakness in the postoperative period in a subset of patients that delays effective rehabilitation therapy (2). Recently, adductor canal compartment blockade has been suggested as an effective alternative while completely sparing any motor involvement (3). We performed this observational study on the use of adductor canal blockade in total knee arthroplasty. Methodology: This study is an IRB approved retrospective observational study conducted on patients between 18-85 years with ASA 3 and below classification who underwent total knee arthroplasty over the past 3 months and received an adductor canal compartment block for postoperative analgesia in lieu of femoral blockade. Intraoperative data collected was duration of surgery, type of anesthesia and tourniquet pressure and duration. Data was collected from POD 0 to POD 2 and included pain variables (NRS, opioid consumption), physical therapy performance variables (bed mobility and balance and transfer tests) and any associated complications. Results: Data was collected on 22 patients. 12 patients received a spinal anesthetic for the surgery and the rest received a general anesthetic. The duration of surgery was 98.9 ±36.2 min and the tourniquet time was 56.1±19.4 min. Tourniquet pressure was 350 mm Hg in 17 patients and 275 mm Hg in 5 patients. The patients received between 20-25 cc of 0.5% Ropivacaine. The NRS on POD 0 was 2.3±3.4 (scale of 1-10) and on POD 1 was 2.6±3.1. The total morphine consumption in first 24 hours was available on 19 patients and was 28.3±9.8 mg iv. Physical therapy milestones: Restriction of ROM for extension of operated knee was 8.7±9.9 degrees on POD 1 and 4.8±3.5 degrees on POD 2. Range of flexion of operated knee was 62.2±15.1 degrees on POD 1 and 70±13.8 degrees on POD 2. The data on quadriceps strength recovery in operated extremity is given in Graph 1. Achievement of other PT milestones is shown in Graph 2. [Quadriceps strength recovery against % of patients] [Number of patients achieving PT milestones ] Conclusion: Our observational study of 22 patients who received adductor canal blockade for total knee arthroplasty shows that adductor canal blockade provides effective postoperative analgesia while causing minimal quadriceps weakness and improves physical therapy milestones. References: 1. Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010 Nov;113(5):1144-62. 2. Ilfeld B. Duke K. et al. The association between lower extremity continous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg. 2010. 111.6: 1552-1554. 3. Jenstrup M, Jaeger P. et. al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: A randomized study. Acta Anaestesiol Scand 2012; 56: 357-364. A72 A COMPARISON OF INTRAVENOUS AND PERINEURAL DEXAMETHASONE ON SCIATIC NERVE BLOCKADE A.M. Weingart, R. Rahangdale, M. Kendall, R. McCarthy, A. Mahil Anesthesia, Northwestern Memorial Hospital, Chicago, IL, USA Introduction: When used as an adjunct in brachial plexus blocks, dexamethasone has been shown 1-2 to increase duration of sensory and motor blockade. Additionally, IV dexamethasone has been shown to decrease post-operative pain. No prior study has evaluated the analgesic effects of perineural dexamethasone as compared to IV dexamethasone. The purpose of this study is to compare the effects of perineural dexamethasone to IV dexamethasone or saline on the quality of recovery of patients receiving sciatic nerve block for foot and ankle surgery. Methods: Following IRB approval, written informed consent was obtained in 70 patients, ASA I-III adults (18-70 y/o) scheduled for foot and ankle surgery to receive an infragluteal parabiceps sciatic nerve block. Subjects were assigned to one of three study groups by a computer generated table of random numbers: Group 1: bupivacaine 0.5% with 1:300,000 0.45ml/kg + 2ml perineural dexamethasone 8mg + IV NS), Group 2: bupivacaine 0.5% with 1:300,000 epinephrine 0.45ml/kg + 2ml NS + IV dexamethasone 8mg in 50ml NS, Group 3: bupivacaine 0.5% with 1:300,000 epinephrine 0.45ml/kg + 2mL NS + 50ml IV NS. Needle positioning was performed using ultrasound guidance. All IV infusions were for 10 minutes initiated at the time of the block. Block duration was assessed as patient reported first toe movement. Pain scores, opioid consumption and quality of recovery (QOR40) were assessed perioperatively. Results: Seventy subjects were enrolled and 68 completed the study. The duration of the sciatic block was longer for the groups that received dexamethasone compared to saline (Table). There was no difference in opioid use among groups. Perineural dexamethasone subjects reported lower pain score pain scores at 24 hr than the saline group, but opioid consumption was similar among groups. There was no difference in QOR-40 scores among groups. Groups Perineural dexamethasone Intravenous dexamethasone Saline Time to first toe movement (hr) 30.6(25.4-33.2) 24.9(21.8-29.9) 18.2(15-20.1)† Pain score 24 hr 48 hr 0(0-2)‡ 4(1.5-5) 2.5(0-5) 3(0-4) 4(0-8) 2(1-6) Opioid consumption (morphine Eq) 0 to 24 hr 23(15-45) 30(15-45) 24 to 48 hr 34(15-51) 23(11-60) 34(23-45) 30(13-45) QOR-40 (48 hours postop) 178(167.5-183.5) 177.5(169-183) 177(170-180) [Duration of Sciatic Block with Dexamethasone] Conclusion: The important finding of this study is that both IV and perineural dexamethasone increase the duration of motor blockade for patients receiving sciatic nerve block for foot and ankle surgery. Further studies are needed to elucidate mechanisms of action, doses, and the role of perinueral and systemic dexamethasone for peripheral nerve blocks. References: 1. Br J Anaesth. 2011 Sep;107(3):446-53 2. Reg Anesth Pain Med 2010; 35 422-6 3. Anesthesiology 2011; 115(3) 575-588 A73 ® SUFENTANIL NANOTAB PCA SYSTEM: PHASE 3 ACTIVE-COMPARATOR DATA VERSUS IV PCA MORPHINE FOR POST-OPERATIVE PAIN 1 2 3 4 T. Melson , D.L. Boyer , H. Minkowitz , P.P. Palmer , M.A. Royal 1 4 2 Anesthesiology, Helen Keller Hospital, Sheffield, Anesthesiology, Beer Simon and Associates, 3 Florence, AL, Anesthesiology, Memorial Hermann Memorial City Hospital Medical Center, Houston, 4 TX, Clinical, AcelRx Pharmaceuticals, Inc., Redwood City, CA, USA Introduction: Intravenous patient-controlled analgesia (IV PCA) is commonly used to manage postoperative pain. However, it is associated with limitations, including programming errors and reduced patient mobility. Sufentanil is an opioid approved as IV and epidural formulations. While it possesses a high therapeutic index with minimal respiratory depressive effects relative to its analgesic effect, high cardiac stability and minimal pharmacokinetic differences based on age, liver or kidney function, rapid redistribution from plasma following IV administration and short duration make it less than ideal for IV PCA. The Sufentanil NanoTab PCA System (SNPS) is a novel preprogrammed noninvasive product in Phase 3 development designed to deliver sublingual sufentanil 15 mcg microtablets with a 20-minute lockout period. This study was designed to evaluate the ability of SNPS to produce comparable patient satisfaction with post-operative pain control to IV PCA with morphine 1 mg q6 min lockout (IV PCA). Patient satisfaction with pain management as measured by the HCAHPS Survey has been identified as a key driver of patient loyalty to a hospital. Methods: In a Phase 3 randomized, open-label, non-inferiority trial at 26 US sites, adult inpatients after major open abdominal or orthopedic surgery (knee or hip replacement) were randomized 1:1 to SNPS or IV PCA for up to 72 hours, stratified by age and type of surgery. The 48-hour Patient Global Assessment (PGA-48) using a 4-point scale (poor, fair, good, excellent), comparing the proportion of patients who responded “good” or “excellent” (collectively “success”) in each treatment arm was defined as the primary endpoint. Pain intensity scores and pain relief scores were obtained as secondary endpoints. Up to 390 patients were to be enrolled to ensure at least 176 patients per group, received treatment and had available primary efficacy data for analysis to provide 90% power to demonstrate therapeutic non-inferiority. A 95% confidence interval (CI) of the difference in success rate between two treatment groups was constructed and if the lower boundary of this CI was not less than -15%, SNPS would be considered non-inferior to IV PCA. Results: 446 patients were screened, 359 were randomized, and 357 received study drug (ITT population: SNPS [n=177] and IV PCA [n=180]) with one patient in each group who did not receive study drug. The mean age for the SNPS group was 63.8 years (30.5% males) and IV PCA group was 64.0 yrs (40% males). Knee arthroplasty represented 32% of surgeries in both groups. The primary efficacy analysis, PGA at 48hr, included 355 patients (176 SNPS and 179 IV PCA). Overall, 78.5% vs. 66.1% of patients achieved PGA 48 “success” for the SNPS group vs IV PCA group, respectively, demonstrating both non-inferiority based on the 95% CI (p < 0.001 using the one-side Z-test against the -15% non-inferiority margin) as well as statistical superiority in favor of the NanoTab System (p=0.009). Conclusion: The Sufentanil NanoTab PCA System provides an alternative patient-controlled analgesia modality which is easy for healthcare professionals to set-up and patients to use. A74 SUBLINGUAL, BUCCAL AND ORAL PHARMACOKINETICS OF THE SUFENTANIL NANOTAB ® P.P. Palmer, M. Evashenk, M.A. Royal Clinical, AcelRx Pharmaceuticals, Inc., Redwood City, CA, USA Introduction: The Sufentanil NanoTab PCA System is a novel preprogrammed noninvasive product candidate in Phase 3 development that dispenses small (3 mm diameter) sufentanil 15 mcg microtablets sublingually with a 20-minute lockout period. Sufentanil is an opioid approved as an IV and epidural formulations. It possesses a high therapeutic index with minimal respiratory depressive effects relative to its analgesic effect in animal studies, a low incidence of cardiac instability and minimal pharmacokinetic differences based on age, liver or kidney function. While these attributes could be ideal in a post-operative opioid analgesic, its rapid redistribution from plasma following IV administration and short duration of action make it less than ideal for intravenous patient-controlled analgesia (IV PCA). Two pharmacokinetic (PK) studies were performed to compare sufentanil PK parameters after sublingual (SL), buccal (BU), oral/gastrointestinal (GI) (PO) and IV routes of administration. Additionally, a literature review for both sufentanil and fentanyl transmucosal delivery and comparisons with oral absorption was performed. Materials/Methods: Two PK studies were performed to evaluate differing oral transmucosal and oral/GI routes of sufentanil NanoTab delivery. In MPS101, five single-dose treatment arms were evaluated, however this presentation will discuss only the PK parameters for SL, BU and PO sufentanil 15 mcg NanoTab administration in comparison to sufentanil IV. In IAP102, a single dose of the sufentanil 15 mcg NanoTab was administered via SL, BU and PO routes and compared to 15 mcg sufentanil IV as a slow IV push over 1 minute. Results: In the MPS101 study, sufentanil bioavailability was 51%, 78% and 7% for the SL, BU and PO routes, respectively, relative to the commercial IV sufentanil formulation tested. The mean T max for SL (0.78h) and BU (0.89h) routes were similar, however for PO, it was significantly delayed at 1.24h. In the IAP102 study, sufentanil bioavailability was 57%, 78% and 6% for the SL, BU and PO routes, respectively. Similarly, the mean Tmax for BU (1.05h), and SL (0.89h) were similar, whereas the PO route was significantly prolonged compared to SL at 1.16h. In both studies, the SL route of administration did not result in a Tmax range beyond 90 minutes. Conclusion: Sufentanil microtablets show significantly reduced oral bioavailability compared to sublingual or buccal administration. Swallowed oral sufentanil absorption is approximately 5-fold less than the oral/GI bioavailability of fentanyl reported in the literature (31%). Avoidance of this delayed gastrointestinal uptake of drug may be the reason behind the narrow range of T max values observed for the SL sufentanil NanoTab compared to published T max ranges for oral transmucosal fentanyl products, which range out to 240 minutes. A75 THE IMPACT OF TEACHING COURSES ON GAINING ULTRASOUND GUIDED REGIONAL ANESTHESIA KNOWLEDGE S. Abbas, A.U. Niazi, J. McVicar, V.W. Chan Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, ON, Canada Introduction: The popularity of ultrasound guided regional anesthesia (UGRA) has increased over the past decade. Success in performing ultrasound-guided peripheral nerve blockade demands sound 1 knowledge of sonoanatomy, good scanning techniques, and proper hand-eye coordination. Learning UGRA can be challenging for novice practitioners. The ASRA Joint Committee recommendations for education and training in UGRA include participation in educational events that include both didactic 2 and hands-on experience. We analyzed the pre and post-test evaluations of three basic ultrasound courses to determine how effective they were for the acquisition of sonoanatomy knowledge. Materials and methods: Since 2004 the regional anesthesia group at our institution has conducted a basic ultrasound course once a year. Each course has an average of 40 registrants. The course is held for three days, the first day includes 8 hours of didactic lectures and the following two days registrant have sufficient supervised time for hands-on scanning sessions which also includes needling practice on phantoms. The course participants mainly include anesthetists who have no or minimal experience in the use of ultrasound in regional anesthesia. Emphasis is mainly given to basic 3 and intermediate ultrasound guided nerve blocks. The course is designed to provide feedback and pointers on how to improve image quality and scanning technique. Registrants have to complete a pre & post-test to evaluate their knowledge of basic ultrasound guided blocks. Each test includes 40 questions that cover a variety of ultrasound and regional anesthesia subjects, such as sonoanatomy, ergonomics, scanning techniques, judgment, recognition of intravenous or intraneural injections and image optimization. The pre and post evaluations of the course are designed to assess the cognitive skills of the participants and unfortunately do not assess their manual skills. Results: We report the pre and post results of three, basic UGRA courses conducted at our institution. In total there were 120 participants, 78 % were beginners (< 20 blocks), 19% were intermediate (20-50 blocks) and only 1% were advanced (51-100 blocks). The average pre-course test score was 72.8% ±2 with a standard deviation of 18.8 and the average post-course test score was 91.26 ±1 with a standard deviation of 10.9. Discussion: Although workshops are resource intensive means to teach sonographic anatomy they remain an effective tool to teach ultrasound device operations and image generation, optimization and interpretation. The findings of this study support the practice pathway recommendations of the 2 ASRA/ESRA joint committee. References: 1. Sites BD, Chan VW, Neal JM, et al. The American Society of Regional Anesthesia and Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2009;34:40-46. 2. Niazi AU, Haldipur N, Prasad AG, Chan VW. Ultrasound-guided regional anesthesia performance in the early learning period: effect of simulation training. Reg Anesth Pain Med. 2012 JanFeb;37(1):51-4. 3. Hargett MJ, Beckman JD, Liguori GA, Neal JM Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med. 2005 May-Jun;30(3):218-25. Funding disclosure: None to disclose. Personal conflicts of interest disclosure: Consultant (GE Healthcare). A76 PAIN RELIEF FOLLOWING THORACOSCPIC SYMPATHECTOMY FOR PALMAR HYPERHYDROSIS A. Abdulmomen Anesthesia, King Saud University, Riyadh, Saudi Arabia Background: Acute pain management following thoracoscopic sympathectomy (TS) has been described in the literature. The combination of interpleural (IP) injection of bupivacaine and intramuscular injection. (I.M) NSAIDs has not been reported. Therefore we conducted this randomized controlled trial to compare this technique to other reported techniques described for postoperative analgesia following TS. Methods: 40 patients scheduled to have TS under general anesthesia for the treatment of hyperhidrosis were randomly allocated into 4 groups. Group 1 received 1.5 mg/kg b.w I.M pethidine at end of surgery. Group 2 received ketoprofen 100 mg I.M at end of surgery. Group 3 received 0.4 ml/kg b.w interpleural bupivacaine 0.5%. Group 4 received a combination of I.M ketoprofen (100 mg) in addition to interpleural bupivacaine (0.4 ml/kg). Postoperative pain was assessed using the 11point numeric rating score (NRS) at 7 different intervals. First, immediately on admission to PACU, every 2 hours for the next 8 hours then at 12 and at 24 hours. Pain was assessed at rest, during deep inspiration and while coughing. ANOVA was used for statistical analysis and Chi-square test for comparing of the data where P values < 0.05 were considered significant. Results: The NRS at rest was 3.2 (1.9), 2.4 (1.6), 3 (1.9) and 0.7 (0.9) at Groups 1, 2, 3 and 4 respectively with significant difference in Group 4 versus other Group (P< 0.05) at 2 hours postoperatively and up to 24 hours postoperatively. The same trend was also found during maximal inspiration and while coughing. Opioid consumption in 24 hours was significantly reduced in Group 4 compared to other Groups. Conclusions: Combination of IP bupivacaine and I.M ketoprofen provided superior analgesia when compared to each modality alone and was better than intramuscular pethidine injection in terms of NRS and the consumption of rescue morphine postoperatively. Further studies are needed on large sample size to confirm our results. A77 THE ANALGESIC EFFICACY OF ULTRASOUND-GUIDED PARAVERTEBRAL BLOCKS IN VIDEO-ASSISTED THORACOSCOPIC SURGERIES: A RETROSPECTIVE ANALYSIS C. Amlong, M. Donnelly, C. Warren, M. Ford 1 2 Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Illumivista Biosciences, Madison, WI, USA Introduction: Video-assisted thoracoscopic surgeries (VATS) have increased in popularity among thoracic surgeons. The advantages of a VATS procedure include decreased postoperative pain, improved cosmetic surgical wounds, lower morbidity, and shorter hospital stays when compared to 1 open thoracic procedures. Paravertebral blocks (PVBs) are a validated method of limiting post2 operative pain for patients undergoing VATS and other thoracic procedures. Our institution began providing ultrasound-guided PVBs for patients undergoing VATS in spring of 2011 with positive feedback from both patients and surgeons. The current study was performed to provide objective data pertaining to the analgesic efficacy of these blocks in patients undergoing VATS. Methods and materials: Following IRB approval, the charts of 44 consecutive patients receiving VATS performed by a single thoracic surgeon between 1/26/11 and 9/28/11were reviewed. Charts of 40 patients were included in the study. Of these, 18 received a preoperative, ultrasound-guided PVB. Patient opioid requirements were recorded from the various perioperative periods, including intraoperatively; in the post-anesthesia care unit (PACU); for the 24-hour period following PACU discharge; and for the patient's entire postoperative hospital stay. These values were converted to intravenous morphine equivalents to facilitate comparison. Patient-reported numerical pain scores (010) from the PACU, the 24-hour postoperative period and from the patients' entire postoperative hospital course were also recorded. Episodes of treated perioperative nausea or vomiting were noted, as was duration of stay in the PACU. Results: We examined 13 perioperative outcomes including opioid administration, pain scores, and nausea in the various perioperative periods as well as duration of PACU stay. Although 12 of 13 studied outcomes demonstrated a trend towards an improved recovery profile in the PVB group, only PACU immediate pain score and intra-operative opioid usage were statistically significantly lower (p=0.048 and 0.014, respectively). While only 2 of these outcomes show statistical significance, the odds of 12 of 13 outcomes showing a favorable trend towards PVBs is highly statistically significant (p< 0.001). Discussion: The current study suggests an improved recovery profile in patients who underwent VATS surgery with a preoperative ultrasound-guided PVB compared to those that did not receive a block. Although our study is underpowered, the resultant trends are consistent with other published research examining the efficacy of landmark driven PVBs. We plan to further study the analgesic efficacy of ultrasound-guided PVBs to validate their usefulness at our institution and perhaps demonstrate improved efficacy with the use of ultrasound guidance. References: 1. Grogan EL, Jones DR. VATS lobectomy is better than open thoracotomy: what is the evidence for short-term outcomes? Thorac Surg Clin. 18:249-258. 2008. 2. Hill SE, Keller RA, Stafford-Smith M et al. Efficacy of single dose, multi-level paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology. 104:1047-1053. 2006. A78 ARE WE BLOCKING COMPARTMENT SYNDROME? INCIDENCE OF UPPER EXTREMITY COMPARTMENT SYNDROME AFTER REGIONAL ANESTHESIA R. Baig, L. Foster, M. Matuszczak, R. Jain 1 2 University of Texas Medical School-Houston, Anesthesiology, University of Texas Medical SchoolHouston, Houston, TX, USA Background: Compartment syndrome is an infrequent, yet devastating complication of extremity traumas in children. Supracondylar fractures of the upper extremity are thought to carry the risk of compartment syndrome [1]. Increasing analgesic requirement is shown to be an early indicator of compartment syndrome [2]. This presents a challenge in treatment, as many surgeons are hesitant to allow regional anesthesia for fear of masking early stages. While there are case reports attributing a delay in compartment syndrome diagnosis to regional anesthesia, there is a lack of published data on incidence. The purpose of this study is to identify the incidence of compartment syndrome after regional anesthesia is performed for postop pain control in pediatric upper extremity injuries. Methods: With IRB approval all our blocks are prospectively entered into the Pediatric Regional Anesthesia Network database. From our PRAN data we evaluated 209 upper extremity blocks performed in pediatric patients from May 2010 to September 2012 at Memorial Hermann Children's Hospital. Patients were followed by the pain service for complications. Data obtained were reviewed for incidence of compartment syndrome. Results: Of 209 upper extremity blocks performed, 98 were in patients with supracondylar fractures of the humerus. The most common cause of supracondylar fracture was a fall. The majority of blocks placed were axillary single shot with ropivicaine, but also included infraclavicular and supraclavicular blocks. All blocks were ultrasound guided. There was zero incidence of compartment syndrome or block complication noted. Discussion: The incidence of compartment syndrome after regional anesthesia for postop pain control in upper extremity fractures in our case series is zero. There are several limitations: lack of a denominator, possible avoidance of regional anesthesia for more severe trauma, surgical bias against regional anesthesia, insufficient power. There is a lack of evidence in the literature that regional anesthesia delays diagnosis of compartment syndrome provided close follow-up [3]. More data is needed so that fear is not the reason to deny appropriate pain control to children. References: 1. Dalens, B. Some current controversies in pediatric regional anesthesia. Curr Opin Anaesthesiol 2006; 19:301-308. 2. Bae DS, Kadiyala RK, Waters PM. Acute Compartment Syndrome in Children: Contemporary Diagnosis, Treatment, and Outcome. J Pediatr Orthop 2001; 21:680-688. 3. Mar GJ, Barrington MJ, Mcguirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009;102 (1): 3-11. A79 PRE-OPERATIVE PAIN MANAGEMENT CONSULTATION DOES NOT IMPROVE POSTOPERATIVE PAIN IN OPIOID-TOLERANT PATIENTS J.C. Bailey, B.L. Ladlie, S.A. Candler, J.M. Irizarry, M. O'Brien 1 2 3 Anesthesiology, Pain Management, Pre-operative Exam Clinic, Mayo Clinic, Jacksonville, FL, USA Introduction: Despite higher doses of opioid medications administered to opioid tolerant patients, this patient population continues to have higher pain scores and a higher incidence of sedation than 1 opioid naive patients in the post-operative period . Pain in opioid tolerant patients is also much slower 2 to resolve . In an effort to improve post-operative analgesia in opioid tolerant patients, we incorporated an evaluation by an expert pain consultant in the pre-operative clinic. All patients on long-acting opioids were eligible for consultation. Post-operative analgesic recommendations were made prior to surgery and were initiated immediately post-operatively. Our hypothesis was that patients seen pre-emptively would have improved pain scores. We also proposed that they would be more likely to receive larger opioid amounts overall and be more likely to receive multi-modal analgesia. This study represents a case-control synthesis of data obtained during the six month period when pain consultation was available in the pre-operative clinic. Material and methods: Patients selected to be evaluated pre-operatively by the chronic pain team were identified through analysis of preoperative opioid requirements in their electronic medical record. The medical record was reviewed for demographic information, pre-operative pain scores, postoperative pain scores, medications and dosages, and type of surgery. Controls were then identified again through EMR data as patients on chronic opioids who did not receive expert consultation preoperatively. The cases and controls were matched based on their pre-operative opioid consumption, in daily morphine equivalents. All opioid conversions were completed using the advanced opioid converter on the globalrph.com website. Results: On average, patients receiving a pre-operative pain consult had a daily pain score greater than their case controlled counterpart on each of the first three post- operative days. Also during this time, the patients receiving a pain consult had a pain score greater than 4 on average greater than 50% of the time compared to the patients who did not receive a consult. The patients receiving a pain consult also had a 30% increase in total cost of hospital stay compared to patients who did not receive a consult. It was noted however that the cost of medications during the hospitalization for patients receiving a pain consult was slightly decreased. [Graph 1] Discussion: Our data fails to show that obtaining a preoperative pain consult improves post-operative pain scores. As expected, the average cost of hospitalization for the patients who received a pain consult was increased. Since this is a small retrospective case-control study (n=15), it is difficult to draw conclusions from this data, however, there is no evidence that pre-operative pain management consultation improves analgesia in opioid tolerant patients. References: 1. Rapp, SE, LB Ready, ML Nessly. Acute pain management in patients with prior opioid consumption: a case-controlled retrospective review. Pain (1995) 62; 195-201. 2. Chapman CR, Donaldson G, Davis J, Ericson D, Billharz J: Postoperative pain patterns in chronic pain patients: A pilot study. Pain Med (2009) 10; 481-487. Funding: None Pain Consult No Consult Total n=15 n=15 Age 60 68.3 Male 0.53 0.20 Extremity Surgery 5 9 Abdominal/Pelvic Surger 1 1 Thoracic Surgery 1 1 Skin/Soft Tissue Surgery 1 2 Endoscopic Surgery 0 2 Neuro/Spine Surgery 7 0 [Table 1] A80 THE USE OF GASSERIAN GANGLION BLOCK IN NEOPLASTIC TRIGEMINAL NEURALGIA - A CASE SERIES S. Srinivasan, M. Issa, S. Narang, D. Boyce Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA Introduction: Trigeminal neuralgia related to cancer may result from local compression of the nerve or local release of inflammatory cytokines, and is usually poorly responsive to medical management (1). We report a series of four patients who achieved prolonged analgesia with repeated gasserian ganglion injections of local anesthetic combined with methylprednisolone. Methods and materials: Four patients with advanced head and neck cancer resulting in intractable trigeminal neuralgia poorly responsive to conservative medical management were treated with gasserian ganglion blocks performed by the extra oral approach. A 22-gauge spinal needle was inserted in a medial, posterior and caudal fashion into the foramen ovale area, with fluoroscopic guidance. The needle was imaged periodically in antero-posterior and lateral views and 0.5 mL of contrast dye Omnipaque 180 mg/ml was injected to confirm accurate location. Next, 40 mg of methylprednisolone and 4 ml of 0.25% bupivacaine was injected in gradual increments with continuous fluoroscopic guidance. The injections were well tolerated in all four cases without any complications. The block was repeated when symptoms returned. Results: The patients received from one to three blocks, and were benefited for 2 to 6 weeks. The use of pain medication decreased in three patients. All patients had 50% or more relief, and 2 patients reported over 80% benefit for the time period. No complications were reported in the patients. (See table) Type of cancer Number of Blocks Duration of pain relief Reduction in pain medication Percent relief Complications Patient 1 Squamous Cell Carcinoma 1 3 weeks Yes 50% None Patient 2 Squamous Cell Carcinoma 2 2 weeks No 50% None Patient 3 Parotid 3 Adenocarcinoma 2 to 6 weeks Yes 80% None Patient 4 Squamous Cell Carcinoma 2 to 6 weeks Yes 80% None [Table 1] 3 [Fig 1] [Fig 2] Conclusion: Treating patients with advanced head and neck cancer may be very challenging in clinical practice. In this case series, we present information regarding the effectiveness and safety of gasserian ganglion blocks in a small series of patients with intractable neoplastic trigeminal neuralgia. We concluded that our patients had satisfactory relief with gasserian ganglion blocks emphasizing the safety and effectiveness of nerve blocks in cancer related pain of this nature. Reference: 1. Cheng T, Cascino T, Onofrio B. Comprehensive study of diagnosis and treatment of trigeminal neuralgia secondary to tumors. Neurology. 1993 Nov;43(11):2298-302 A81 A RANDOMIZED COMPARATIVE EVALUATION OF TWO APPROACHES FOR POSTERIOR LUMBAR PLEXUS BLOCK USING REAL TIME ULTRASOUND GUIDANCE - A PILOT STUDY 1 1 1 2 J. Brookes , S. Ganapathy , R. Sondekoppam Vjayashankar , S. Adhikary , L. Subramanian 1 1 2 University of Western Ontario, Anesthesia, University of Western Ontario, London, ON, Canada, Milton S Hershey Medical Centre, Hershey, PA, USA 3 Introduction: Lumbar plexus block (LPB) is a well accepted method for post operative analgesia in patients undergoing lower limb surgery. Karmakar et al reported an approach using an paramedian inplane ultrasound probe in a case series of 5 patients. They found it impossible to visualize the whole path of the needle while using real-time ultrasound due to the plexus depth and steep angle of insertion. Capdevila et al described an approach contacting the transverse process and advancing inferior to it. We add off-plane ultrasound guidance to this approach to position the needle on the transverse process with the probe in transverse axis. Adding USS allows visualization of needle tip location with hydro-location and estimation of depth of deeper structures. Methods: 19 patients undergoing total knee arthroplasty were randomized to receive one of the two approaches. We hypothesized that off-plane needle insertion for lumbar plexus would be quicker and woulf result in higher success rate compared to an in-plane approach. Block onset was checked every 5 minutes for 30 minutes. Pain scores were collected for 48 hours. Patients were followed up at one week. Results: 19patients underwent randomization. Demographic data were similar between groups: In plane Off plane ASA status (I,II,III) (1,5,4) (0,3,6) BMI - mean (SD) 28 (5.4) 30 (3.3) Height - mean (SD) 165 (8.0) 170.6 (11.5) [Demographics] Visualization of the lumbar plexus and adjacent structures while in-plane could be clear but was frequently challenging, requiring 40% of the in-plane blocks to be converted to off-plane. [In plane] Visualization of the transverse process could usually be seen in the off-plane transverse approach. [Off plane] There were no significant difference in procedure times, block success rates or postoperative verbal reported pain scores (VRS) between the two groups. No adverse events occurred. Procedure details: In plane Off plane P 666 (444) 622 (237) 0.81 Crossover rate (n/group 4/10 total) 0/9 0.087 Block complete/incomplete (sensory and motor) at 30 minutes (n) 3/6 2/4 >0.99 Block complete/incomplete 4/5 (sensory) at 30 minutes (n) 3/3 >0.99 Block complete/incomplete (motor) at 30 minutes (n) 2/4 >0.99 Procedure time: mean(SD) [Procedure details] 3/6 Pain outcomes: In plane Off plane P mean(SD) VRS at rest/ on movement 12hrs 2.8(3.7)/4.1(4.0) 2(8.2)/4(3.9) 0.62/0.95 mean(SD) VRS at rest/ on movement 24hrs 2.2(3.0)/3.8(3.0) 1.8(2.6)/3.9(2.9) 0.74/0.94 mean(SD) VRS at rest/ on movement 36hrs 1.25(1.6)/2.5(2.1) 2(1.9)/3.4(1.7) 0.39/0.33 mean(SD) VRS at rest/ on movement 48hrs 1.5(1.5)/4.8(3.4) 1.2(1.1)/3.0(0.9) 0.67/0.16 [Pain outcomes] Discussion: Visualization of anatomical structures was frequently difficult. Despite this pain scores were low. Due to the steep needle angle and plexus depth, visualization of the needle tip is likely to remain a challenge in a significant proportion of patients. The off-plane approach can be viewed as a useful extension of the nerve-stimulator technique. Funding: None. Personal conflicts of interest disclosure: Nothing to disclose. A82 BUPIVACAINE EXACERBATES FACIAL MOTONEURON (FMN) AXOTOMY-INDUCED CELL DEATH S. Byram, S. Byram Loyola University Chicago, Maywood, IL, USA The appropriate management of pain after an injury or surgical procedure has been shown to improve the outcome of patients by quickening recovery and reducing hospital costs. Anesthesiologists commonly use local anesthetics (LA) to perform nerve blocks that result in temporary pain control during or after a surgical procedure. While infrequent, nerve damage resulting from regional anesthesia can be devastating, and the exact mechanism of injury remains unknown. The 1-4 neurotoxicity of LA has been well documented . LA have been shown to cause growth cone 1-4 inhibition and neuron death, demyelination, and infiltration of inflammatory cells . Because LA are frequently applied to sites where peripheral nerves may be growing (e.g., chemical, burn, mechanical injury or neurodegenerative disease), their effects on growing neurons should not be ignored in clinical practice. There are no current studies in the literature that examine the effects of LA on diseased or injured nerves, a commonly encountered clinical scenario. The purpose of this study was to determine if LA exacerbate FMN axotomy-induced cell death. C57B/6 mice were subjected to a right facial nerve axotomy, with the left (uninjured) side serving as control. At the time of axotomy we placed gelfoam impregnanted with 1) saline, 2) 2% lidocaine or 3) 0.75% bupivacaine. The brains were removed 4 -weeks post-axotomy, frozen, and 25 mm cryostat sections collected through the facial nucleus and thionin stained. FMN were counted, and a ratio between cut and uncut FMN calculated. The average percent FMN survival in mice treated with saline (control group) 4 weeks 5 after facial nerve axotomy was 80%, which is similar to previously published data . The average percent FMN survival in mice treated with lidocaine was 78%, which is not significantly different, compared to the saline control group. The average percent FMN survival in mice treated with bupivacaine was 35%, a significant decrease of 45% in FMN survival relative to the saline treated control group. [Percent FMN Survival] Our data suggest that bupivacaine placed on a transected nerve stump at the time of injury exacerbates FMN cell death. It has been proposed that once a nerve is damaged, it becomes more 6 susceptible to injury elsewhere along the nerve . For example, patients with diabetic neuropathy have a higher incidence of nerve entrapments, and a cervical radiculopathy stemming from the neck 6 increases the likelihood of carpal tunnel syndrome . Furthermore, there is ample literature debating the safety of sciatic nerve blocks for knee replacement surgery, given the 20% incidence of sciatic nerve injury from the surgery itself and therefore the risk of double crush phenomenon. Thus, an improved understanding of the effects of LA on neurons may lead to strategies to identify patients at higher risk for permanent neural deficits after peripheral nerve blocks and/or decrease the risk of neural deficit following peripheral nerve blocks. Scott Byram - Cadence Pharmaceutical speaker bureau 1 2 3 4 Werdehausen et al., 2009; Radwan et al., 2002; Perez-Castro et al., 2009; Kalichman et al., 1989; 6 Byram et al., 2004; Upton and McComas 1973 5 A83 A FIVE-DAY MEDICAL STUDENT REGIONAL ANESTHESIA CURRICULUM T. Caggiano, C. Guheen, M. Kalsi 1 2 Anesthesia, Hospital for Special Surgery, Anesthesia, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA Introduction: Residencies and careers in anesthesiology have generated increasing interest among medical students over the past several years. Most medical school curricula offer minimal exposure to the specialty; furthermore, this exposure is often focused on general anesthesia. Experience and understanding of airway management is the primary goal of most medical students during these clerkships. Quite often, exposure of medical students to regional anesthesia is minimal or completely absent. The primary reason for this is that many departments have difficulty providing opportunities in regional anesthesia for their residents, let alone medical students. The Department of Anesthesiology at Hospital for Special Surgery (HSS) is affiliated with Weill Cornell Medical College and hosts medical students for 1 week of their 4-week clerkship in anesthesia. We are an orthopedic specialty hospital that performed 34,779 OR cases in 2012 with 12,051 acute pain procedures. In keeping with our departmental mission to continually foster interest, growth and education in regional anesthesiology, we have created a five-part medical student curriculum to facilitate achievement of such goals during the medical student's five-day experience. The 5-day curriculum for medical students highlights the fundamentals of regional anesthesia and acute pain medicine. Our goal was to choose appropriate topics for medical students that would introduce them to the subspecialty and potentially increase their interest in career development of both anesthesiology and regional anesthesia. Methods: The authors reviewed multiple general anesthesia textbooks, specialty texts in regional anesthesia and landmark articles to formulate the background for the curriculum. In addition, the authors had lengthy discussions with attending staff, fellows, residents and medical students to determine which topics were of utmost importance to include and emphasize upon. Results: This five-part curriculum, designed to coincide with the five days of the medical student rotation here at HSS, contains daily learning objectives, assigned readings, daily questions and cases, key concepts and relevant images. A84 PRELIMINARY EXPERIENCE WITH THE COMBINATION OF THROMBOPROPHYLAXIS WITH RIVAROXABAN FOR DEEP AND SUPERFICIAL BLOCKS J.E. Chelly, D. Schilling Department of Anaesthesiology and Pain Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Introduction: Rivaroxaban is a new oral Xa inhibitor approved for thromboprophylaxis in orthopedics. The risk of major bleeding associated with the combination of thromboprophylaxis with rivaroxaban and deep and superficial blocks is unknown. This report details our initial experience with the combination of thromboprophylaxis with rivaroxaban and deep and superficial blocks. Method: All patients undergoing classic and minimally invasive total hip and total knee replacement with continuous nerve blocks and receiving rivaroxaban for thromboprophylaxis were included in this analysis. Blocks were performed prior to surgery (a continuous lumbar plexus for total hip replacement and a continuous femoral and gluteal sciatic for total knee replacement). Rivaroxaban 10 mg daily was started the day following surgery. The perineural catheters were removed on postoperative day 1 (hip) and postoperative day 2 (knee) without consideration for the time of administration of rivaroxaban. Following the removal of catheters patients were monitored for clinical symptoms of major bleeding. Results: A total of 21 patients including 6 total hip replacement and 15 total knee replacement benefited from the combination. No significant bleeding was recorded. Discussion: Although this represents a very small series and this group recognized that additional data are required; this represents the only data available on the combination of the combination of thromboprophylaxis with rivaroxaban and deep and superficial blocks. Like with other drugs used for thromboprophylaxis the estimated risk of major bleeding of the combination of thromboprophylaxis and deep and superficial blocks is unknown it is important to recognize that the administration of rivaroxaban has been associated with major bleeding including a retroperitoneal hematoma. Since evidence support the value of continuous nerve blocks for joint replacement our data do not suggest that thromboprophylaxis with rivaroxaban should not be consider at this point a contra-indication of performing continuous deep and superficial blocks. References: 1. Dentali F, Riva N, Crowther M, Turpie AG, Lip GY, Ageno W. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of the literature. Circulation. 2012 ;126:2381-91 2. Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, Cushner FD, Lotke PA, Berkowitz SD, Bandel TJ, Benson A, Misselwitz F, Fisher WD; RECORD4 Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial. Lancet. 2009 ; 373:1673-80 A85 VALIDATION OF AN IN-LINE INJECTION PRESSURE MONITOR USING A REFERENCE DIGITAL PRESSURE RECORDER 1 1 1 2 3 4 1 J. Choi , E. Lin , J. Gadsden , C. Vandepitte , P. Gautier , I. Hasanbegovic , A. Robinson , X. Sala5 Blanch 1 2 3 St. Luke's Hospital Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of 4 5 Physicians & Surgeons, New York, NY, USA, University Hospitals Leuven, K.U.L., Leuven, Clinique 6 Ste Anne-St Remi, Brussel, Belgium, University of Sarajevo, Sarajevo, Bosnia-Herzegovina, 7 University Hospital Barcelona, Barcelona, Spain Introduction: Injection pressure monitoring (IPM) has been suggested as a means to detect needlenerve contact and/or intrafascicular injection (1, 2). A disposable in-line IPM (BSmart, Concert Medical, Norwell, MA) has been gaining acceptance as a clinical tool for injection monitoring. However, no study has validated its performance against a digital reference standard (DRS). In this study, we tested the accuracy of BSmart to detect needle-nerve contact using a DRS as a control in fresh human cadavers. Methods: This study was approved by the IRB of KU Leuven, Belgium. Needles were inserted using US to contact and slightly displace the C5, C6, C7 nerve roots in fresh frozen cadavers. Pressure was slowly applied manually to the syringe (20 mL) until spread of injectate was observed by a blinded investigator. Pressure data was recorded simultaneously with an in-line IPM (BSmart) and a digital pressure transducer (PendoTECH, Princeton, NJ) through a 150 cm low-compliance conduit (LectroCath, Vygon, Ecouen, France) and a 22 gauge blunt-tipped stimulating needle (Stimuplex-A, B Braun, Inc), Figure 1. [Injection Pressure Apparatus Setup] Results: Pressures reported by BSmart correlated well with recordings by electronic pressure transducer. The BSmart monitor continuously displayed pressures through color-coded indicators (White: 1 to 15 psi; Yellow: 15 to 20 psi; and Red: >20 psi). The BSmart manometer detected all instances (100%) of opening injection pressure >20 psi recorded by the digital pressure transducer with needle-nerve contact, Table 1. BSmart Pressure Monitor Digital Pressure Transducer (psi) Cadaver 1 (n = 18) Red (>20 psi) 28.58 (range: 26.03-30.50) Cadaver 2 (n = 18) Red (>20 psi) 32.81 (range: 29.42-34.95) [Needle-Nerve Contact Opening Injection Pressure] Discussion: Under the conditions of our study, all attempted injections with needle-nerve contact in cadavers generated opening injection pressures >20 psi. BSmart accurately detected injection pressures >20 psi in all instances. References: (1) Reg Anesth Pain Med 2012;37:525-529, (2) Acta Anaesthesiol Scand 2007; 51:101-107. A86 FACILITATION OF ULTRASOUND-GUIDED REGIONAL ANESTHESIA USING A HEADMOUNTED VIDEO DISPLAY - AN EMERGING TECHNIQUE? R. Przkora, P.J. Courtney, D. Solanki Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA Introduction: Regional Anesthesia and Analgesia (RA) are established techniques in Anesthesiology. The best approach to administer RA is still under discussion; however, ultrasound-guidance during needle placement appears to be the preferred standard of care. While ultrasound-guidance improved outcomes in RA, its use is not without problems, especially in regard to the coordination between the hands (ultrasound probe and needle) of the provider and the display of the ultrasound screen in the distance, requiring head and hand adjustments of the provider. This problem results in: Frequent needle redirections, repeated skin punctures, increased time to perform the procedure, increased discomfort for the patient and provider and finally, increased risk of adverse events. The close display of the ultrasound-screen in front of the provider`s eyes using special glasses could improve this situation. Materials and methods: We used a commercially available head-mounted video display (HMD), a binocular image monitor worn like regular glasses (video eyewear). The HMD was connected to the ultrasound screen, displaying the ultrasound image on the monitors in front of the provider`s eyes. After IRB approval from our institution (UTMB), the HMD was introduced in our clinical practice. Results: The HMD has been used successfully in over 10 patients requiring RA of the upper or lower extremities. No complications have been noted during this initial evaluation period. [Head-mounted video display (HMD) - front] Conclusion: We introduced for the first time the use of the HMD technique for ultrasound-guided RA in clinical practice. Studies with patients are currently conducted to evaluate if the HMD improves coordination compared to the conventional ultrasound-guided approach. A87 AN INEXPENSIVE AND EASILY-MADE PHANTOM MODEL FOR TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK TRAINING AND ASSESSMENT C.A. Czeczok, K. Schroeder University of Wisconsin, Madison, WI, USA Introduction: In the recent past, ultrasound imaging use for regional nerve blocks has become increasingly popular. Transversus abdominis plane (TAP) blocks are also increasing in popularity given both their effectiveness in producing post-operative analgesia and the short amount of time needed to place these blocks. Training tools are necessary for learning how to obtain the images and effectively place these blocks in the correct tissue plane, and there is a lack of an inexpensive training model. Methods: In creating a TAP block phantom model for ultrasound-guided training, we utilized inexpensive and easily obtainable materials. Materials included a plastic container, gelatin, psyllium fiber, fruit roll-ups, and olive oil. The tissue mimic was made with 250ml of boiling water mixed with 20g of unflavored gelatin and 10g of sugar-free psyllium fiber. The fascial plane was created with two fruit roll-ups placed together with a thin film of olive oil between. A Sonosite M-Turbo® ultrasound machine with a 13.6 MHz linear probe used to obtain images. Two neurostimulating needles were used to administer normal saline. Both insulated (Arrow StimuQuik®) and non-insulated (Pajunk®) needles were used; each was 22ga x 50mm. Results: Ultrasound images obtained from the gel phantom training model, both pre- and postadministration of saline solution, very closely mimicked those found in an adult human. Pre-injection, out-of-plane injection, and in-plane injection images are seen below. Discussion: Described above is an inexpensive, easily-made gel phantom model that can be used for ultrasound-guided TAP block training. This provides training that is accurate, efficient, and safe for patients. A88 SEDATION WITH TARGET-CONTROLLED PROPOFOL INFUSION DURING OPEN REDUCTION AND INTERNAL FIXATION OF HIP FRACTURE IN ELDERLY PATIENTS UNDER ULTRASOUND GUIDANCE LPB VERSUS CLSB Z. Da-Qiang, X. Tao, J. Wei Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China Background and Objective: Patients undergoing open reduction and internal fixation of hip fracture usually are elderly and present with different associated comorbidities. Studies have demonstrated the increased risk of mortality after hip fracture especially during the first year, and excess mortality risk may persist for several years after fracture.It was identified that lumbar plexus block and combined lumbar plexus and sacral plexus block could be well performed during open reduction and internal fixation of hip fracture. The aim of this study was to assess target-controlled propofol infusion as a technique of anaesthesia for open reduction and internal fixation of hip fracture in elderly patients under ultrasound guidance lumbar plexus block(LPB) or combined lumbar plexus and sacral plexus block(CLSB); and to evaluate which nerve block was superior for this surgery, lumbar plexus block or combined lumbar plexus and sacral plexus block. Methods: Sixty patients(>70 years old)with American Society of Anesthesiologists (ASA) physical status of 1-3,undergoing scheduled for open reduction and internal fixation of hip fracture received LPB with 30 ml 0.5% ropivacaine at level L3-4 (LPB group, n=30) or CLSB with 30 ml 0.5% ropivacaine at level L3-4 and 10 ml 0.5% ropivacaine at sacral plexus (CLSB group, n=30). The target-controlled propofol infusion was started immediately after positioning the patient on the operating table. The initial target concentration was 1.5 µg/mL. The infusion rate was adjusted every 5 , min by increasing or decreasing the target concentration by 0.2 µg/mL steps based on the patients blood pressure (BP), heart rate (HR), and bispectral index (BIS)and conscious state (score of 1 on OAA/S sedation scale). The performance time of nerve block, minimal, maximal, optimal target concentration,respiratory and haemodynamic parameters, total propofol dose, additional fentanyl needs ,frequency of spontaneous movement and incidences of associated complications were recorded. Results: The performance time was shorter in the LPB group than in the CLSB group(274.00±80.54 Vs 348.50±57.88s, P=0.000). Minimal, maximal, optimal target concentration were significantly different in the LPB and CLSB groups(1.50±0.05µg/ml vs 1.38±0.13µg/ml, P=0.006;2.06±0.27µg/ml vs 1.67±0.16µg/ml, P=0.000; 1.97±0.28µg/ml vs 1.57±0.23µg/ml, P=0.000). There was no significant difference in respiratory and haemodynamic parameters, total propofol dose between the LPB group and the CLSB group.The additional fentanyl needs and frequency of spontaneous movement in LPB group were more than that of CLSB groups.No other associated complications occurred. Conclusion: Target-controlled propofol infusion as a technique of anaesthesia for open reduction and internal fixation of hip fracture in elderly patients under ultrasound guidance lumbar plexus block(LPB) or combined lumbar plexus and sacral plexus block(CLSB) is safe and efficacious. In addition, combined lumbar plexus and sacral plexus block(CLSB) is more sufficient for hip fracture surgery than lumbar plexus block. A89 ASSOCIATION OF ACUTE POST-OPERATIVE PAIN WITH COMT FUNCTIONAL VARIATION IN PATIENTS AFTER TOTAL KNEE ARTHROPLASTY (TKA) 1 2 2 2 1 2 2 F. Dai , J. Chelly , C.M. Greco , K.L. Vulakovich , L. Qin , D. Landsittel , L. Crossett , I. Belfer 1 2 2 Yale Center for Analytical Sciences, New Haven, CT, Department of Anesthesiology, University of 3 4 Pittsburgh, Department of Psychiatry, UPMC Center for Integrative Medicine, Center for Research 5 on Health Care Data Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA Introduction: Studies on human pain genetics revealed that common polymorphisms in certain genes (i.e., COMT, GCH1) affect pain perception and neural processing in multiple human cohorts, yet no prior study has been performed in patients following TKA. Here we aimed to determine whether genetic variations of COMT gene are associated with acute post-operative pain in TKA patients. Material and methods: Caucasian patients from a major medical center (Shadyside hospital of UMPS) were recruited prospectively prior to TKA surgery and followed through their hospital stay. Clinical, demographic as well as baseline pain data was collected before surgery. Post-operative pain in the affected knee at movement was assessed three times using numerical pain score (0-no pain, 10-highest pain) at day 1, 2 and 3, respectively. Five COMT single nucleotide polymorphisms (SNPs) rs2097603, rs6269, rs4633, rs4818, and rs4680 were genotyped using TaqMan technology (Applied 1 Biosystems, CA). Regression analyses using PLINK software was used to model main effect of SNP or haplotype on pain outcome after adjustment for covariates. A p-value of less than 0.05 was considered to be statistically significant. Results: A total of 149 patients (63 male, age mean 63.5 ±9.2) were genotyped. All the SNPs are in Hardy-Weinberg equilibrium. We identified significant associations between pain at day 1 in femaleonly patients with rs6269 (p = 0.023) and rs4818 (p = 0.020), and trend of associations with rs4633 (p = 0.077) and rs4680 (p = 0.077). Females with at least one copy of minor allele of the SNPs had higher acute pain than those who do not. Haplotype analysis showed that the low pain sensitivity 2 (LPS) haplotype 'GCGG' was significantly associated (p = 0.05829) with pain score at day 1. No association was identified in males. Discussion: We identified that LPS haplotype previously reported as associated with less sensitivity to painful stimulation and less chronic pain in females with temporomandibular joint disorder (TMD)2, was associated with more acute post-operative pain (day 1) in TKA female patients. We therefore confirmed sex-specific effects of COMT and revealed an interesting modality-specific effect since COMT seems to contribute oppositely to acute and chronic pain. These findings, upon further confirmation, can help clinicians in prediction and management of postoperative acute pain in TKA patients. Funding disclosure: The study was supported by NIH/NIDCR (0408-CT2048) to PI Dr. Jacques Chelly. Personal conflicts of interest disclosure: The authors declare that they have no conflicts of interest. References: 1. Purcell S, Neale B, Todd-Brown K, et al. PLINK: A Tool Set for Whole-Genome Association and Population-Based Linkage Analyses. The American Journal of Human Genetics. 2007;81(3):559-575. 2. Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum. Mol. Genet. January 1, 2005 2005;14(1):135-143. A90 IMPACT OF COMBINED SPINAL EPIDURAL (CSE) ON PERIOPERATIVE COURSE FOR TOTAL HIP ARTHROPLASTY J. Eiler, K. Schroeder, M. Donnelly, B. Anderson, A. Dickman, A. Dickman University of Wisconsin Hospital and Clinics, Madison, WI, USA Introduction: Total hip arthroplasty (THA) is a common orthopedic operation to improve mobility and quality of life. In a continual effort to improve perioperative outcomes and patient experience, regional anesthesia is a growing area requiring a delicate balance between pain control and rehabilitation functionality. General anesthesia offers reliable surgical conditions, but with increased risk of nausea and no perioperative regional pain control. Spinal anesthesia avoids the complications of general anesthesia and offers a dense, predictable surgical block but little pain control postoperatively. Lumbar epidural anesthesia offers the option for continued post-operative pain control, although utilization may be limited by early ambulation goals, potent anticoagulant administration, and unilateral blocks. At our institution, we utilize Combined Spinal-Epidural (CSE) anesthesia to maximize the benefit of the two neuraxial techniques. Given the variability of patient management by our orthopedic service, a portion of patients have their epidural utilized overnight (typically 0.15% ropivacaine with 10 mcg/ml hydromorphone at a rate of 6 ml/hr) stopped at 0600 on POD#1 and the remainder have it removed immediately following surgery. A Cochrane review by Choi et al in 2003 demonstrated no significant advantage to regional anesthesia beyond the early 4-6 hour mark in total joint patients for pain control. This review attempted to determine the effect of our postoperative analgesia infusion on outcomes following THA. Materials and methods: Following IRB approval, a retrospective chart review analysis of prospective data collection was completed at an academic university hospital. Participants included 320 patients undergoing elective THA (111 CSE with epidural overnight, 85 CSE with epidural removed in OR) from 3/11/2011 to 3/28/2012. Baseline patient characteristics and outcome variables were analyzed including pain, opioid administration, opioid related side effects, rehabilitation outcomes, etc. To standardize opioid administration, all opioids administered were converted into intravenous morphine equivalents. A chi-squared test was used to analyze categorical variables while a Mann-Whitney test was used for continuous variables. Results: Baseline patient characteristics including age, gender and BMI were similar between groups. CSE with postoperative infusion of local anesthetic and opioid resulted in significant decreases in PACU, POD#0, and POD#1 peak and mean pain. CSE with postoperative epidural infusion also resulted in significant decreases in PACU, POD#0, POD#1, and total opioid administration. Postoperative nausea, rehabilitation goals and total hospital time were not impacted by postoperative analgesic technique. Discussion: The goal of this study was to analyze perioperative outcomes and patient experience for patients undergoing THA. Our results demonstrate a significant benefit with postoperative epidural infusions compared to intraoperative neuraxial blockade alone for pain control. There are other mechanisms for postoperative pain control (i.e. lumbar plexus block) that may also be beneficial to patients undergoing THA. Further study may be helpful to further define which postoperative analgesic regimen is superior in patients undergoing THA. References: Choi PT et al. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Review. 2003; 3. Funding/personal conflicts of interest disclosure: Nothing to disclose. A91 PATIENT ORIENTED OUTCOMES AFTER REGIONAL ANESTHESIA FOR ORTHOPEDIC TRAUMA: A PROSPECTIVE COHORT STUDY N.M. Elkassabany, L. Fan Cai, L. Pieczynski, J. Gaertner, S. Mehta, J. Ahn, J. Liu 1 2 3 University of Pennsylvania, Anesthesiology and Critical Care, Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA The need to measure, compare, and improve the quality of postoperative pain management is increasingly sought by health care consumers, payers, and professionals. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) (figure 1) for quality improvement of pain management in hospitalized adults has been published by the American Pain Society (APS) in 2010 1 to address this need . The questionnaire assesses the quality of postoperative pain management in five domains; pain severity and sleep interference, interference with activity, severity of adverse effects, affective subscale, and patient perception and satisfaction with their care. The impact of regional anesthesia and analgesia on the patients' surgical experience as a whole and 2 their satisfaction with their care is better categorized as patient oriented outcomes . Certain instruments are especially designed to measure quality of recovery, quality of life, and patient satisfaction. The importance of these outcomes is increased with the implementation of the pay per performance system. A second aim of this study is to measure the quality of recovery in the first 24, 3 and 48 hours after surgery suing the Quality of Recovery-9 (QOR-9) . Material and methods: Patients admitted to the orthopedic trauma service at the hospital of the University of Pennsylvania with a single extremity fracture. Patients with multiple traumas are excluded. Sample size: 100 patients will be enrolled in this study. Patients will be classified into one of two groups, Regional Anesthesia (RA) group and Systemic Narcotic (SN) group, based on whether regional anesthesia or analgesia has been used as part of their postoperative pain management protocol. Outcome end points: 1- APS-POQ-R in the first twenty four hours after surgery. 2- QOR-9 questionnaire at 24 and 48 hours Results: We are presenting the preliminary results for the first twenty patients enrolled in this study. The quality of pain management was better in the regional anesthesia group when compared with the systemic opioid group. Regional anesthesia scored significantly better in four of the five subscales assessed by the APS-POQ-R. Patients who had regional anesthesia had better pain control (p=0.02) and less interference with sleep (p=0.03) and less adverse effects (p=0.07). Patients in the regional anesthesia group also scored better in the affective subscale (p=0.001) domain and in their satisfaction with pain management (p=0.08). There was no significant difference between the two groups in terms of interference with activity (p=0.13). Patients in the RA group scored better on the qor-9 at 24 hours. Average score was 13(12-15.5) versus 11.5 (11-13) for the systemic opioid group. However, this difference was not statistically significant (p=0.13). The QOR score at 48 hours was also similar between the two groups. Discussion: Patient centered outcomes, are often overlooked in the regional anesthesia literature. These outcomes should probably get more attention in future research studies. Figure (1): The APS-POQ-R [Figure 1, Page 1] [Figure 1, Page 2] References: 1- Gordon DB, et al. J Pain 2010;11(11):1172-86. 2- Wu CL, Fleisher LA. Anesth Analg 2000;91(5):1232-42. 3- Myles PS, et al 2000;28(3):276-80. A92 THE PLACE AND ROLE OF TAP-BLOCK IN SPINE SURGERY 1 2 A. Ezhevskaya , A. Ovechkin , Z. Prusakova 1 1 Anesthesiology and Reanimation, Research Institute of Traumatology and Orthopedics, Nizhny 2 Novgorod, Anesthesiology and Reanimatology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia Introduction: Transverse abdominal plane (TAP) block is a new approach to the bilateral blockade of the afferent nerves of the abdominal wall through the lumbar triangle of Petit. In 2008 the technique was offered to perform of hypochondrium oblique block of the TAP using ultrasound [1, 2]. We evaluated its analgesic efficacy in patients during the first 24 hours perioperative period of anterior/anterolateral retroperitoneal lumbar surgery in a randomized, controlled, clinical trial. Material and methods: The study included 60 patients (women - 22 men - 18, age - 19-45 years, ASA I-II). The following spine surgeries were performed: anterior or anterolateral retroperitoneal approaches for spinal fusion L4-5 (12 of them - graft from the iliac bone, 38 - mesh, 10 - vertebral body prosthesis). All patients were randomly divided into two groups: Group T (n=30) had TAP-block and endotracheal anesthesia with sevoflurane and fentanil during surgery and Group G (n=30) had general anesthesia with sevoflurane and fentanil and then systemic administration of opioids after surgery. After induction of anesthesia and tracheal intubation patients in Group T were underwent unilateral TAP-block 0.5% solution of 25 ml of ropivacaine after aspirate under ultrasound control (SonoScape, China) on the mid-axillary line, between the iliac crest and the costal margin. Before incision, patients in Group T received fentanyl 1 mcg/kg and then were entered it when necessary. At the end of the surgery after the closure of the wound the catheter was placed into the TAP under ultrasound and 5 ml of 0.5% ropivacaine solution was injected. After surgery patients in Group T were administered boluses of 20 ml of ropivacaine 0.2% solution, 2 times a day for 3 days. After surgery patients in both groups were administered ketorolac IM, 2 times a day for 3 days. Demographics, pain at rest and in motion, nausea and vomiting were assessed during the first 24 hours after surgery. Results: Patients with TAP-block needed for additional administration of narcotic analgesic occurred for longer times. 14 patients in Group T (47%) did not need for opioids. In the Group T there was significantly less pain at rest and in motion, and higher patient satisfaction. In comparison with Group G, cases of nausea and vomiting were significantly less in patients of Group T. There was no pain in 12 patients in Group T (40%) during the first 24 hours. Discussion: We conclude that using the TAP-block with ropivacaine as a component of anesthesia in anterior/anterolateral retroperitoneal lumbar surgery provides better analgesia reduces the intensity of pain after surgery, the need for opioids, improves postoperative patient comfort, and patient satisfaction. The TAP-block is and effective regional component combined general anesthesia. It is easily and safely to perform under ultrasound control. References: 1. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesthesia and Intensive Care 2007;35:616-617. 2. Laffey J, McDonnell J. Subcostal Transversus Abdominis Plane Block Under Ultrasound Guidance. Anesthesia and Analgesia 2008;106:675. Funding: Health Ministry, Russia Personal conflicts of interest disclosure: Nothing to disclose. A93 EFFECT OF TWO-LEVEL THORACIC EPIDURAL ANESTHESIA ON HAEMODYNAMICS AND HEMOSTASIS DURING DORSALIS CORRECTION OF SCOLIOSIS 1 A. Ezhevskaya , A. Ovechkin 2 1 Anesthesiology and Reanimation, Research Institute of Traumatology and Orthopedics, Nizhny 2 Novgorod, Anesthesiology and Reanimatology, I.M. Sechenov First Moscow State Medical UniversityM, Moscow, Russia Introduction: Anesthetic management of corrective operations is among the most sophisticated and insufficiently solved problems of modern major spine surgery. Search for solutions of the problems, ways and means of implementing anesthesiological protection remain relevant [1, 2]. We assessed the effects of epidural anesthesia on systemic haemodynamics, the hydration state of the lungs and the haemostatic system during surgical corrections of scoliosis. Material and methods: The study included 135 patients, aged from 12 to 25 years with spinal deformities of grade III-IV. All patients were randomly divided into 2 groups. Two-level (Th4-5 and Th10-11) thoracic epidural anesthesia (EA) with 0.75% ropivacaine (15-25 ml) and 200 mcg of fentanil and general endotracheal anesthesia with sevoflurane (0.8-1.5% vol.) were used in the Group E (n = 70) and only general anesthesia with sevoflurane and fentanil was used in the Group G (n = 65) during the surgery. After the surgery in the Group E analgesia was performed by prolonged EA by setting at the end of surgery two epidural catheters with ropivacaine, fentanil and epinephrine using infusion pump. Patients in the Group G had systemic administration of opioids by controlled analgesia. Blood loss and coagulation parameters were assessed during the surgery. Systemic hemodynamic parameters were measured using non-invasive monitoring of hemodynamic parameters on the basis of impedance cardiography (ICG) using a «NICCOMO» (Germany). Results: The study revealed a statistically significant reduction in intraoperative blood loss on 50% in the Group E (568 ml, p=0.0013). Noninvasive hemodynamic monitoring showed that EA does not lead to life-threatening disorders in myocardial contractility, cardiac output, systemic vascular resistance and critical increase of the content of extravascular lung water. However surgical interventions were accompanied by significant changes in the parameters of hemostasis and characterized hypercoagulated changes in both groups, but more expressed in the Group G. Discussion: We suppose that the main reason for a significant decreasing of intraoperative blood loss due to effects of sympathetic blockade of epidural analgesia. Evoked controlled hypotension, low blood pressure in the epidural veins and intraosseous pressure are main factors of affecting blood loss. The results show that the reaction of the haemostatic system in the operation is the simultaneous amplification of coagulation and fibrinolysis. Most likely, the role of the thoracic EA is to control the activation of hemostasis / fibrinolysis. Thus, stage epidural analgesia in the surgical correction of scoliosis can be successfully used both during and after surgery, providing a reliable multi-level nociception, less blood loss, and modulation of the endocrine stress response. References: 1. Blumenthal S, Min K, Nadig M, Borgeat A. Double epidural catheter with ropivacaine versus intravenous morphine: a comparison for postoperative analgesia after scoliosis correction surgery // Anesthesiology. - 2005; 102. - P.175-180. 2. Wenk M, Ertmer C, Weber TP, et al. 2010 Feasibility and Efficacy of Preoperative Epidural Catheter Placement for Anterior Scoliosis Surgery // Anesthesiology. - 2010. - Vol 113. - P. 353-9. Funding: Health Ministry, Russia Personal conflicts of interest disclosure: Nothing to disclose. A94 REGIONAL ANESTHETIC INJECTION PRESSURES BY SKILLED ASSISTANTS IN A SIMULATED ULTRASOUND GUIDED TECHNIQUE E. Fawzy, J. Carter, R. Heij, A. Ali, M. Liu, J. Gibson, P. Young Anaesthesia, Queen ELizabeth Hospital, King's Lyn, King's Lynn, UK Introduction: Injection during regional anesthesia risks permanent nerve injury when pressures in 1 excess of 11 PSI are applied . Previous studies have demonstrated that perception of appropriate, 2 safe injection pressure varies widely . The performance of ultrasound (US) guided regional anesthesia requires a two-handed approach and hence the syringe is held, and injection performed, by a skilled assistant. We tested operating department practitioners (who routinely perform this injection in our institution) during a simulated ultrasound guided regional anesthetic recording the pressure of injection. Materials and methods: Requirement for formal ethical approval was waived by our institutional research governance committee. Written consent was obtained. Whilst an investigator was performing an US guided block on a chicken leg or phantom, each participant (n=20) was asked to assess US visualization of 2mL aliquots of local anesthetic. Injection was performed by each participant using a 20mL syringe (Terumo, Egham, UK) as per normal institutional practice. Each was asked to inject and aspirate exactly as they would do clinically and specifically told not to inject if they did not feel happy to. Unknown to the participants, prior to the commencement of each 2mL aliquot injection, a second investigator applied a constant known pressure to the injection system using a calibrated constant pressure generator (Fluke Biomedical, Everett, WA) at 5, 10, 15, 20, 25 and 30 PSI in random order. Participants indicated when they were unhappy to inject and the needle was moved. The next pressure in the random sequence was then surreptitiously applied. If injection was performed then the injection pressure was changed during the aspiration period of every 2mL aliquot. Results: Fourteen of the 20 participants (70%) injected at 15 PSI or above (see Figure 1). Four participants (20%) injected at 20 PSI, two (10%) at 25 PSI and two (10%) at 30 PSI. Interestingly, all participants who injected at 20 PSI and above were male. Furthermore, three of the six participants who were not willing to inject at 15 PSI or higher had more than 20 years experience. [Figure 1] Discussion: Avoiding intra-neural injection is a fundamental requirement during the performance of any regional anesthetic technique. An anesthesiologist using a two-handed US guided approach relies on a skilled assistant to inject the local anesthetic solution. Our results confirm that the majority of skilled participants would inject at higher pressures than considered to be safe. References: 1. Hadzic et al. Combination of Intraneural Injection and High injection Pressure Leads to Fascicular Injury and Neurological Deficit in Dogs Reg Anes Pain Med 2004;29:417—423 2. Claudio et al. Injection Pressures by Anesthesiologists During Simulated Peripheral Nerve Block Reg Anes Pain Med 2004;29:201-205 A95 COMBINED FEMORAL NERVE BLOCK AND MULTIMODAL ANALGESIA REDUCES EARLY POSTOPERATIVE PAIN SCORES AT REST AND DURING PHYSICAL THERAPY IN PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY L.O. Mark, R. Bengali, E.A. Jacob, A.A. Freiberg, R. Dorman, V.J. Hansen, R. Peloquin, P. Stefanovich, K.H. Fleischmann 1 2 Department of Anesthesia, Critical Care, and Pain Medicine, Department of Orthopedic Surgery, 4 Department of Physical Therapy Services, Harris Orthopedic Lab, Massachusetts General Hospital, Boston, MA, USA 3 Introduction: Femoral nerve blocks and multimodal analgesia are known to improve pain control at 1 rest and decrease hospital length of stay following total knee arthroplasty . However, it is less clear whether these interventions affect early ambulation pain scores in the postoperative period. We investigate early postoperative (POD 0 and 1) pain score reduction after total knee arthroplasty at rest and during physical therapy ambulation in patients who received multimodal oral analgesics, femoral nerve block, and intra-operative multimodal peri-articular injection. Materials and methods: Sixty-four patients who underwent total knee arthroplasty by a single orthopedic surgeon at Massachusetts General Hospital in 2010 and 2012 were randomly selected and retrospectively enrolled in the study. Patients in the test group received preoperative multimodal oral analgesics (celecoxib 400 mg, oxycodone continuous release 10-20 mg, and acetaminophen 975 mg), femoral nerve block (20 mL of 0.2% ropivacaine with 1:400,000 epinephrine), and intra-operative multimodal analgesia injection (ketorolac 30 mg, epinephrine 0.5 mg, clonidine 0.08 mg, and ropivacaine 300 mg in normal saline with a final volume of 150 ml) (n=33). Patients in the control group did not receive these interventions (n=31). The two groups were queried for postoperative pain scores at rest, and 59 of the 64 patients were further studied for pain scores during physical therapy with ambulation. All patients received general or spinal anesthesia and standard postoperative pain medications as needed. Pain scores were reported using a standard zero through ten scoring system by physical therapy. Statistical calculations were performed with two-tailed, unpaired t-tests with significance set at p< 0.05. Results: Mean early postoperative pain scores (POD 0 and 1) were significantly reduced in the test group compared to the control group at rest (2.6 vs. 3.7, p=0.03) and during active physical therapy (3.6 vs. 5.4, p=0.002) (Figure 1). A trend towards improved pain scores on POD 0 compared to POD 1 was noted, though the sample size is small. The test and control groups had equal distributions of spinal and general anesthetics. [Figure 1] Discussion: In this retrospective study, femoral nerve block plus multimodal analgesia significantly reduced early postoperative pain scores at rest and during physical therapy with ambulation. Stronger significance was noted for early ambulation. Our data suggests that this combination mode of therapy may also reduce pain scores immediately postoperatively (POD 0), enabling very early mobilization of patients undergoing total knee arthroplasty. This may have significant clinical benefit as it may lower 2 the incidence of deep venous thrombosis . Further studies with larger sample sizes are needed to confirm these observations. References: 1. Tripuraneni KR, Woolson ST, Giori NJ. Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores. Orthopedics. 2011 Mar 1;34(3):173. 2. Nakao S, Takata S, Uemura H, Nakano S, Egawa H, Kawasaki Y, Kashihara M, Yasui N. Early ambulation after total knee arthroplasty prevents patients with osteoarthritis and rheumatoid arthritis from developing postoperative higher levels of D-dimer. J Med Invest. 2010 Feb;57(1-2):146-51. COIs and Funding: none A96 INTRODUCING ULTRASOUND-GUIDED PARAVERTEBRAL BLOCKS INTO CLINICAL PRACTICE FOR TOTAL MASTECTOMY: A RETROSPECTIVE REVIEW OF OUR FIRST YEAR OF EXPERIENCE J.S. Green, R. Theron, N. Amyotte, S.M. Hamilton, M. van Wijngaarden-Stephens, B.C.H. Tsui, Edmonton Academy of Regional Anesthesia 1 2 Anesthesiology and Pain Medicine, Surgery, University of Alberta, Edmonton, AB, Canada Introduction: Clinical evidence suggests a significant improvement in pain control and post-operative nausea and vomiting when using paravertebral blocks compared to oral and intravenous analgesia 1;2 alone. Ultrasound-guided paravertebral blocks were introduced into clinical practice at the University of Alberta Hospital in November 2010 for patients undergoing total mastectomy. This retrospective review compares a time-matched cohort of patients receiving paravertebral blocks to a cohort that did not. We hypothesized that patients undergoing a paravertebral block would experience less pain and nausea than patients not receiving the block. Material and methods: We performed a retrospective review of 100 consecutive total mastectomy cases from November 2010. Following institutional ethical approval, patients who underwent total mastectomy were identified via the surgeon's office. A retrospective medical chart review was then performed to identify opiate use, pain scores, incidence of nausea, vomiting, anti-emetic use, and complications relating to placement of paravertebral block. Outcomes of patients who received paravertebral blocks were then compared to those that did not. Groups were not stratified by breast cancer stage. Results: A total of 102 patients were included in the review. Of these, 34 received a paravertebral block and 68 did not. No incidence of pneumothorax or significant bradycardia/hypotension relating to paravertebral block was found. Seven patients (20%) who received a paravertebral block reported a pain score >5 in the post-operative recovery room (PARR). We also observed a significant decrease in both the total intra- and post-operative IV opiate use and incidence of nausea and vomiting in the paravertebral group (Table). [Table] Discussion: There is a learning curve with any new procedure, and failures and complications are expected to occur more frequently during this learning period. A total of seven members of the acute pain service including fellows were learning the technique during this time. It was therefore reassuring that no complications were found, and we showed a significant reduction in opiate use and nausea incidence during this introductory period. Although we were disappointed that 20% of patients reported pain scores greater than five in PARR, the causes of pain are multifactorial and include pain from the site of axillary node dissection, which is not covered by the paravertebral block. We expect to improve these results by standardizing simple oral analgesia, routine anti-emetic use, and anesthetic regime. Optimization of paravertebral local anesthetic concentration, volume, technique, and possible catheter placement may also improve outcome. References: 1. Schnabel A et al., Br. J. Anaesth. 2010; 105:842-52. 2. Tahiri Y, et al. J. Plast. Reconstr. Aesthet. Surg. 2011; 64:1261-9. Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest: Nothing to disclose. Table. Opiate use and incidence of nausea, vomiting, and/or antiemetic use. A97 CASELOAD VARIABILITY OF AN ACUTE PAIN SERVICE AT A LEVEL ONE TRAUMA CENTER: IMPLICATIONS FOR MANPOWER MANAGEMENT R. Guffey, E. Conrad, F.J. Auerbach, J.E. Chelly Anesthesia, UPMC - Posner Pain Center, Pittsburgh, PA, USA Introduction: Acute pain services (APS) are often considered a cost center, and therefore resources required to cover the needs of the service are often difficult to secure. This is as much on the side of the department as the hospital. Characteristic to an APS in a trauma center are frequent unscheduled consults. The goal of this study was to assess the trauma related consult variability and determine how it impacts manpower coverage. Methods: The number of unscheduled trauma consults was reviewed over a period of 12 months. Since August was identified as the month with the greatest number of unscheduled consults, this month was chosen for further study. Next, APS consults between August 1-31 were analyzed using our IRB approved database. Only data from weekdays were considered (Monday through Friday). After determination that our data were normally distributed, data are presented as mean ± SD. Results: The APS was consulted on 395 patients over the 23 days of the study period. Of those consults 254 (63%) were scheduled. Twenty two of the scheduled consults (9% of scheduled) were cancelled the morning of surgery. The distribution of consults varies daily (Figure 1). A total of the 358 patients seen by APS and 269 (75%) were blocked. In 90% of cases the block was performed preoperatively and 60% of consults were for inpatients. Most patients managed medically were for minor rib fractures, large burns or acute on chronic pain who did not consent for blocks. Our scheduled vs. actual number of patients to block as first start OR cases (7:30 AM) varied significantly according to the days of the week. Sixty one percent of nerve blocks placed on inpatients were catheters, while only 16% of outpatient nerve blocks were catheters. Staffing was not associated with requirement for postoperative nerve blockade. Discussion: Our results show that case variability did not significantly impact our ability to block patients preoperatively during a heavy trauma month. This was due to the model used to schedule staff for our APS. It is based on a flexible schedule such that staffing to each site is modulated according to the number of blocks scheduled the day before at each site. Although a specific regional attending is assigned to the APS on a daily basis (2 on Monday and Friday), at least one additional attending is scheduled to work in the OR with the ability to help supervise blocks if necessary. Inadequate staffing was not associated with the need for postoperative nerve blockade. The majority of cases of postoperative nerve blockade were due to the inability for patients to come to the preoperative area with adequate time to be blocked without delaying the surgery. [Figure 1] Figure 1 Average number of patients seen by the AIPPS. The number of patients scheduled split by day of the week is significant by ANOVA (p < 0.005). * Standard deviation References: None Funding: Departmental Conflicts of interest: Nothing to disclose A98 IMPROVING NEEDLE VISUALIZATION BY NOVICE RESIDENTS DURING AN IN-PLANE ULTRASOUND NERVE BLOCK SIMULATION USING THE CIVCO INFINITI™ NEEDLE GUIDE R. Gupta, J. Lane, B. Allen, Y. Shi, J. Schildcrout 1 2 3 Anesthesiology, Biostatistics, Biostatistics and Anesthesiology, Vanderbilt University, Nashville, TN, USA Background and objectives: Ultrasound-guided Regional Anaesthesia with in-plane needle approaches can be challenging due to difficult needle visualization. We hypothesized that the CIVCO TM Infiniti needle guide can help reduce the time it takes novice regional anesthesiologists to perform a simulated ultrasound-guided nerve targeting procedure and enhance the visualization of the needle. Methods: Sixteen volunteers were randomized to repeat a single nerve targeting simulation task 4 times with and 4 times without the needle guide in a crossover study design. Endpoints were time to complete the nerve targeting, needle visualization, number of passes, and needle approximation to the target. Results: The needle guide reduced median time to complete the task by 27% (95% confidence interval: 4% - 44%) and increased the odds of effective needle visualization by 355% (95% confidence interval: 171% - 737%). A learning benefit was also noted with multiple attempts regardless of whether the needle guide was used or not. TM Conclusions: The CIVCO Infiniti needle guide can help reduce the time needed to complete a simulated nerve targeting procedure and enhance needle visualization for the novice sonographer in a phantom gel simulation. There was no significant reduction in the number of needle passes or in improvement of target approximation noted. A99 PRE-INCISIONAL PARAVERTEBRAL AND PARASPINOUS BLOCK FOR MASTECTOMY AND RECONSTRUCTION M. Guzman Community Surgery Center East, Indianapolis, IN, USA Introduction: Pre-incisional thoracic paravertebral blocks(PTPVB) are associated with reduced pain scores in women undergoing mastectomy and reconstruction. Multiple thoracic levels may need to be blocked to obtain adequate analgesia. These observations prompted the hypothesis that placement of a multi-orificed soaker catheter lateral to T 5/6 to C7 could provide additional pain relief to a single PTPVB. Method: 61 women were scheduled for unilateral or bilateral modified radical mastectomy with reconstruction. All patients received a single, ultrasound guided PTPVB, transverse approach, at T4/5, ropivacaine 0.5% 15 ml/side. A 6 inch needle/sheath(Figure 1) was placed 1-2 cm lateral to the spinous process, directly over the top of the external intercostal muscles from T5/6 to C7. The 6 inch needle was removed, leaving a peel away sheath in place. A 5 inch multi-orificed catheter was placed through the sheath and the sheath was then removed. An elastomeric infusion device containing ropivacaine 0,2% was connected at 7 ml/side. PACU patients were placed on a multimodal pathway consisting of intravenous acetaminophen,NSAIDS, and oxycodone prn. Hydromorphone .5mg was given prn. Paraspinous catheters were dosed with ropivacaine 0.5% 15ml/side on arrival to PACU and again the following morning. Patients were discharged with their elastomeric pump at 4 ml/hour for an additional 36 hours. Results: 96 PTPVB were performed for mastectomy and reconstruction. Remarkably, 10 of the 60 patients reported zero pain and received no opiates. 50 patients immediate PACU scores were 37/10, with all responding to IV hydromorphone, usually 1 mg or less. Most patients had pain scores of 2-4/10 within 3 hours of starting the multimodal regimen. 50 patients had pain scores of 1-3/10 at 7 am postoperative day one, and at this time all paraspinous catheters were dosed with ropivacaine 0.5% 15 ml/side. All women reported additional pain relief and better range of motion after the am bolus. Pain scores on discharge were 0-2/10. No patients showed signs of an epidural block or had rebound pain after removal of the paraspinous catheter. Discussion: PTPVB has been shown to decrease acute pain scores and also reduce chronic pain in mastectomy patients at 1,6, and 12 months. For this reason our patients received a single PTPVB with each paraspinous catheter. It is common to perform more than one PTPVB to provide greater coverage. Bilateral surgery can easily require 4-6 individual blocks. Extending the duration of a PTPVB requires placing a continuous catheter and increases the complexity of this block. A multiorificed catheter was chosen that would extend from T 5/6 to C7. Ultrasound Figure 2 shows a transverse view of the paraspinous catheter soaking the intercostal muscle and explains the phenomenal effect we have seen using this multilevel continuous intercostal nerve block. Our patients have shown extremely low pain scores and great range of motion on discharge. Presented is a relatively simple technique for continuous intercostal nerve blocks. [Figure 1] [Figure 2] A100 RIVAROXABAN OR CONVENTIONAL THROMBOPROPHYLAXIS IN ROUTINE CLINICAL CARE SUBGROUP ANALYSIS OF THE XAMOS STUDY BY TYPES OF ANESTHESIA USED 1 2 2 3 4 S. Haas , G. Holberg , R. Kreutz , M.R.L. Lassen , L. Mantovani , A.G. Turpie 1 5 2 3 Technical University Munich, Munich, Global Medical Affairs, Bayer HealthCare AG, Institut für 4 Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin, Berlin, Germany, Glostrup 5 Hospital, University of Copenhagen, Copenhagen, Denmark, CIRFF, Center of Pharmacoeconomics, 6 Federico II University of Naples, Naples, Italy, Department of Medicine, Hamilton Health Services, Hamilton, ON, Canada 1 Introduction: Data from the non-interventional phase IV XAMOS study reflected the benefit-risk profile of rivaroxaban seen in the phase III RECORD studies for the prevention of venous 2-5 thromboembolism after elective total hip or knee replacement surgery. The aim of this subanalysis was to describe the pattern of anesthesia used and the potential influence of anesthesia type on outcomes in the XAMOS study. Material and methods: The types of anesthesia and adverse events, including symptomatic thromboembolic and bleeding events, were reported by the investigators. In this analysis, subgroups were generated according to the type of anesthesia and the type of surgery (i.e. hip or knee replacement surgery). Types of anesthesia were categorized as: general, neuraxial (including combinations of spinal/epidural and local anesthesia), peripheral, combinations of general and other anesthesia, and other combinations (Table). Results: Of the 17,701 patients enrolled, 8778 received rivaroxaban and 8635 received standard of care (SOC) pharmacological thromboprophylaxis. In the SOC group, 81.7% of patients received low molecular weight heparin (LMWH) and 7.9% received fondaparinux. The types of anesthesia used were similar between the rivaroxaban and SOC groups. Neuraxial anesthesia was used more than any other form of anesthesia (59.1-61.3%) in patients receiving rivaroxaban, SOC, or LMWH (Table). General anesthesia was used more often in patients undergoing hip surgery (38.8-43.2%) compared with those undergoing knee surgery (29.4-29.5%; Table). There was a numerically lower incidence of symptomatic thromboembolic events in patients who had neuraxial anesthesia compared with those who received general anesthesia in both treatment groups. Further clinical outcomes according to different types of anesthesia and surgery will be presented. Discussion: This subanalysis showed that, in routine clinical care in unselected patients undergoing major hip or knee surgery, neuraxial anesthesia was used more often than other types of anesthesia, which is consistent with the pattern observed in the RECORD studies. General anesthesia was used more frequently in hip surgery than in knee surgery, although no difference was observed in the anesthesia used between the rivaroxaban and SOC groups. References: 1. Turpie AGG et al. Br J Haematol 2012;157:9-10. Abstract 20. 2. Eriksson BI et al. N Engl J Med 2008;358:2765-2775. 3. Kakkar AK et al. Lancet 2008;372:31-39. 4. Lassen MR et al. N Engl J Med 2008;358:2776-2786. 5. Turpie AGG et al. Lancet 2009;373:1673-1680. Funding source: This study was funded by Bayer HealthCare Pharmaceuticals. Table. Types of anesthesia used in the XAMOS study All surgery types Hip surgery Knee surgery Combinati Other Gener Neuraxia Peripheral on of Gener Neuraxia Gener Neuraxia combinatio al l* ** general al l* al l* ns and others Rivaroxaba 36.9 n, % 59.1 0.6 3.1 0.1 43.2 54.4 29.5 64.7 SOC, % 36.3 59.8 0.7 2.9 0.1 41.8 56.0 29.5 64.7 LMWH, % 34.6 61.3 0.8 3.0 0.1 38.8 58.9 29.4 64.5 *Neuraxial includes: spinal; spinal and epidural with or without indwelling catheter; spinal and femoral block; spinal and paravertebral block; spinal and LIA; epidural without and with indwelling catheter; epidural without indwelling catheter and femoral block; epidural without indwelling catheter and paravertebral block; epidural without indwelling catheter and LIA; epidural with indwelling catheter and femoral block; epidural with indwelling catheter and paravertebral block; epidural with indwelling catheter and LIA. **Peripheral includes: femoral block, paravertebral block, LIA, femoral block and paravertebral block, femoral block and LIA, paravertebral block and LIA. LIA, local infiltration anesthesia; LMWH, low molecular weight heparin; SOC, standard of care. A101 CAN LOCAL ANESTHETIC SPREAD SEEN ON ULTRASOUND PREDICT ONSET, SUCCESS, AND DURATION OF INTERSCALENE NERVE BLOCKS? 1 2 2 1 M.W. Harbell , J. Geerling , P.E. Hess , P. Aleshi 1 Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA 2 Introduction: Recent studies suggest that a circumferential spread of local anesthetic (LA) around the sciatic nerve leads to faster onset and improved sensory block [1]. Achieving this “donut sign” has become a common goal in ultrasound-guided blocks. However, this has not been demonstrated for interscalene nerve blocks (ISB) [2]. We hypothesized that spread of LA seen on ultrasound can predict onset of motor blockade, block success, and block duration of ISB. Methods: After obtaining IRB approval, 93 ASA I-III patients received ISB with 30 ml bupivacaine 0.375% with epinephrine 5mcg/ml prior to upper extremity surgery under general anesthesia. ISB was performed with ultrasound, nerve stimulation or with a combination of the two depending on anesthesiologist preference. Immediate pre- and post-block ultrasound images were obtained by the same operator. The onset of sensory and motor blocks (loss of shoulder abduction), perioperative analgesic use, success rate, and patient satisfaction were recorded. Three visualization scores were used to analyze the appearance of LA spread on ultrasound immediately post-block injection. These scores were based on the number of trunks visualized, distortion of nerves, donut spread of LA, and tracking of LA along nerve in the loop image of the nerve. Results: 82 of the 93 patients enrolled in the study had complete pre- and post-block images. The overall failure rate was 8.6%. None of the visualization scores developed correlated with onset of motor blockade, block duration, or block success. 71% of the failed blocks appear to have a “donut sign” spread of LA. Block failure was not statistically different between nerve stimulator and ultrasound guided techniques (NS 7/65, 11% vs. US 1/24, 4%; p= 0.44). Block failure significantly correlated with lack of motor block prior to surgery (2/8 (25%) vs. 69/82 (84%), p= 0.001). Block failure was associated with lack of ulnar and median sensory block onset prior to surgery (Ulnar 2/8, 25% vs. 60/82 (73%), p= 0.01; median 4/8 (50%) vs. 73/82 (89%), p= 0.01), but not with lack of radial sensory block onset prior to surgery. Discussion: Post-injection spread of local anesthetic does not predict successful ISB, nor does it correlate with onset or duration of anesthesia. Further, achieving a “donut sign” during ISB does not guarantee a successful block. Lack of motor block was the strongest predictor for block failure. Lack of ulnar and median sensory block, but not radial, was also predictive of block failure. References: 1. Missair A, Weisman RS, Suarez MR, Yang R, Gebhard RE. A 3-Dimensional Ultrasound Study of Local Anesthetic Spread During Lateral Popliteal Nerve Block. RAPM 2012, 37(6): 627-632. 2. Lang RS, Kentor ML, Vallejo M, Bigeleisen P, Wisniewski R, Orebaugh SL. The impact of local anesthetic distribution on block onset in ultrasound-guided interscalene block. Acta Anaestheiol Scand 2012, 56: 1146-1151. Funding: Beth Israel Anesthesia Foundation Personal conflicts of interest disclosure: Hess - consultation for Philips Ultrasound, Inc. A102 SCANNING ELECTRON MICROSCOPIC ANALYSIS OF CUT EPIDURAL CATHETERS. A PILOT STUDY 1 1 G. Holck , E.A. Goytizolo , L.C. Tsen 1 2 2 Department of Anesthesiology, Hospital for Special Surgery, New York, NY, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, USA Introduction: Anesthesiologists due to tip contamination during epidural catheter (EC) placement or 1 adapter disconnection , eventually, can cut the EC. This practice could generate microfragments from the cut tip, which could migrate to the epidural space and lead to epidural granuloma. We hypothesized that cutting the EC produce microfragments and the Scanning Electron Microscopy (SEM) technique permits the identification of these microfragments at the edge of the cut catheter and in the distilled water (DW) injected through the EC. Material and methods: Three different types of EC from different manufactures (B. Braum Medical ® Inc. Perifix , BD Medical Perisafe™, Arrow International Inc. FlexTip Plus®) were analyzed under SEM. A standard SEM view of each catheter type was obtained before intervention to determine the baseline pattern for each manufacturer. The ECs were divided in 2 groups with 5 ECs of each type (n=15 per group); using a standardized cutting method the first group was cut with scissors (SC group) and the second group cut with scalpel blade (BL group). After a SEM view of the cut tip was acquired, 0.2 ml of DW was injected using a connector attached to the cut tip. Then, this tip was reanalyzed and also the content washed out from the EC was analyzed to search for microfragments. Results: In this observational study, as a preliminary result, the images obtained show presence of microfragments at the cut EC tip in 100% of the samples analyzed. The fragments size widely varied (12.5 - 116.25 µm). The scalpel group had less traumatic microscopic pattern and generated less microfragments than the scissors group. After cutting the EC, attaching the connector and injecting DW the EC tips reanalyzed showed no more loose fragments that had been washed out by the DW. The analysis of the DW injected through the cut EC demonstrated presence of microfragments. [BBraum catheter ] [Arrow catheter ] Discussion: A few case-reports in the literature associate epidural granuloma formation and prior 2,3 continuous epidural anesthesia . However, this association is not completely understood. Possible 4 4 causes could be trauma related to EC placement , contained infection , organized epidural 2 5 6 hematoma , drug-induced reaction and particles from surgical gloves . To our knowledge, fragments from the EC have not been evaluated as potential cause for epidural granuloma following continuous epidural anesthesia, especially if the EC has been cut. According to our findings, using SEM, it is evident that cutting the EC generates microfragments at the cut tip. These fragments can be dislocated into the epidural space when a liquid solution is injected through the cut EC and potentially generate epidural granuloma. References: 1. Anaesthesia 2000; 55: 192-3. 2. Anaesth Intensive Care. 2010;38:779-80. 3. Orthopedics 2009;32:293. 4. Am J Neuroradiol 2005; 26:991-995. 5. Neurosurgery 2002;50:78-86. 6. Rev Esp Anestesiol Reanim. 1999;46:60-6. Funding disclosure: Support was provided solely from departmental sources. Personal conflicts of interest disclosure: Nothing to disclose. A103 ARTHROPLASTY CARE REDESIGN: IMPACT OF SPINAL DOSING ON POST ANESTHESIA RECOVERY UNIT LENGTH OF STAY AFTER TOTAL HIP ARTHROPLASTY A. Holman, E. Jacob, K. McCarty, M. Rozanski, R. Dorman, O. Evgenov, K. Fleischmann, A. Freiberg, M. Gargarian, W. Levine, J. Lewis, V. Modest, P. Stefanovich, S. Vassallo, J. Wang, L. Warren, L. Wollman-Kliman, J. Rathmell, R. Peloquin, MGH Arthroplasty Care Redesign Team 1 2 Department of Anesthesia, Critical Care, and Pain Medicine, Department of Physical Therapy 3 Services, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA Introduction: In 2011, the Massachusetts General Hospital Arthroplasty Care Redesign Team was charged with evaluating arthroplasty care with the aim of reducing cost while maintaining or improving quality. A previously identified limitation to early ambulation and thus overall length of hospitalization was extended length of stay in the PACU (PACU LOS), particularly among patients receiving spinal 1 anesthesia (SA) for Total Hip Arthroplasty (THA). This led to a systematic examination of THA SA dosing and subsequent efforts to reduce those doses. In this study, we analyzed the influence of SA Bupivacaine dose on PACU LOS after THA in comparison with use of general anesthesia (GA). Materials and methods: Using our anesthesia perioperative electronic health record, we retrospectively reviewed all adult patients who underwent THA at MGH from January 1, 2010 September 30, 2012. The primary endpoint was PACU LOS. All data are shown as mean ± standard deviation and were analyzed using two-tailed t-tests with significance set at p < 0.05. Results: PACU LOS for patients receiving high-dose and low-dose SA was 265±98 min and 230±88 min, respectively (Figure 1, Table 1). [Figure 1 - PACU LOS as a Function of SA Dose] Period 1-Period 2 Hips Low-dose (< 15mg) Hips High-dose (≥ 15mg) Average PACU LOS (min) 230 265 PACU LOS SD 88.0 98.2 Average Dose of 0.5% Bupivicaine (mg) 12.2 18.1 [Tabe 1 - PACU LOS and SA Bupivicaine Dosing] SA dosing decreased from 18.7±2 mg in Period 1 to 15.3±2 mg in Period 2 (Table 2, p < 0.001). Average Dose of 0.5% Bupivicaine for Spinal Arthroplasties in Period 1 and Period 2 Average Dose in Period Average Dose in 1 Quarter 1 Period 2 Average Dose in Quarter 2 Period 2 Average Dose in Quarter 3 Period 2 18.7 ± 2 mg 16.4 ± 2 mg 15.3 ± 3 mg 16.2 ± 2 mg [Table 2 - THA Average Dose for SA] PACU LOS in those receiving SA decreased from 272±97 min during Period 1 to 242±94 min during Period 2 (p < 0.001). PACU LOS also decreased in those receiving GA from 222±97 min during Period 1 to 204±113 min during Period 2 (Figure 2, p = 0.03). [Figure 2 - Average THA Surgical and Recovery Times] For all patients undergoing THA, recovery time decreased from 249±100 min during Period 1 to 221±107 min during Period 2 (p < 0.001). The overall reduction in PACU LOS during Period 2 was 10,052 minutes of PACU recovery time. Discussion: Extended PACU LOS delays physical therapy and early mobilization following THA. In January 2012, MGH anesthesia practitioners were encouraged to reduce 0.5% Bupivacaine doses used for THA. Examination of our anesthetic outcomes led to a significant reduction in SA doses and an associated reduction in PACU LOS. Further study is needed to establish optimal SA dosing assuring sufficient anesthesia duration while minimizing recovery time. References: 1. McCarty et al., “Impact of General versus Spinal Anesthesia on Post-Anesthesia Care Unit Recovery Time Following Total Hip and Knee” ASA Conference Abstract October 2012. 2. Macfarlane et al., “Does Regional Anesthesia Improve Outcome After Total Hip Arthroplasty?” Br.J.Anaesth (2009); 103:335-45. Funding: MGH Center for Quality and Safety Clinical Innovation Award Nothing to disclose. A104 LOW INCIDENCE IN DELAYS FOR FIRST CASE STARTS WITH THE IMPLEMENTATION OF A DEDICATED BLOCK TEAM B.-S. Hoter, M. Semenza, J.-L. Horn 1 2 Surgical Services, Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA Introduction: With the current push to have all patients in their operating room (OR) in a timely fashion for first case starts, regional anesthesia (RA) adds a potential delay. To minimize first case delays associated with RA techniques we implemented a separate block team out of the OR that performs all perioperative RA. In January 2012 our institution funded a specialized block nurse dedicated to coordinating care with the regional anesthesia team. In April of that year the block team started tracking factors responsible for OR delays. The goal of this study is find the incidence and reasons for first case delays in patients being taken care of by the block team. Methods: Our specialized block team consists of an attending anesthesiologist and a resident on a RA rotation both otherwise unassigned in the OR, an anesthesia technician, and a block nurse. The team has a dedicated space with ultrasound machines, block carts and procedure bays with full monitoring capability. The block team briefs to plan the next day's RA with a focus on communication with all parties involved. Potential block candidates are identified and placed on an expedited list to be ready for the block team by 06:30. When a patient is included in the pathway, the end of the procedure and the readiness for OR transportation is recorded. For any patient not ready by 07:25 for 07:30 in-room start time, the reason for the delay is identified and then verified with the responsible party and validated by the preoperative charge nurse keeping track of case timing. Data from April to July 2012 were collected and reasons for delays were recorded. Results: The distribution of delays is illustrated in Fig. 1. During the 4-month period the block team took care of 190 patients for first case starts. Twenty-eight patients (14.7%) arrived late to the OR. The top three reasons were: 1) lack of surgical consent (9 patients, 4.7%); 2) difficulties with block placement (7 patients, 3.7%); and 3) late patient arrival (5 patients, 2.6%). Among the 7 patients delayed because of the block, 6 were due to peripheral nerve blocks and 1 due to epidural. [Fig. 1] Conclusions: Implementation of a program with a dedicated block team, early planning and constant communication with all parties involved results in low incidence first case delays. Data collection on accurate timing and reasons for delay will most likely facilitate further improvement in OR efficiency. Ref: Wright JG. Can J Surg, 53(3);167-170, 2010 Mariano E. J Clin Anesth, 21(4);253-257, 2009 Funding: This study was funded internally by the Department of Anesthesiology and Perioperative Medicine and the Perioperative Services at Oregon Health & Science University A105 RISK FACTORS AND MEDICAL CONSUMPTIONS ASSOCIATED WITH POSTOPERATIVE NAUSEA AND VOMITING 1 2 2 2 2 2 P.-J. Liao , M.-L. Tsai , C.-Y. Huang , D.-Y. Kerr , T.-S. Huang , C.M. Yang , K.-H. Hsu 1 2 2 Oriental Institute of Technology, New Taipei City, Chang Gung University, Taoyuan, Taiwan R.O.C. Introduction: Post-operative nausea and vomiting (PONV) is one of the most common side effects associated with surgical procedures. The incidence of PONV after general anesthesia is about 25% to 30%. PONV can result in negative impacts on medical quality and the subsequent recovery as well as quality of life. This study aimed to analyze the factors associated with PONV and their medical consumptions with data from general anesthesia patients. Materials and methods: The study is a retrospective follow-up design, which collected data from general anesthetic patients admitted in a medical center from January 1, 2008 to December 31, 2008. A total of 27,715 study subjects were collected from Quality Assurance database. This study has obtained patient and Institutional Review Board (IRB) approval. Univariate statistics and a multiple logistic regression model were applied to explore the factors associated with PONV. Results: The characteristics of high risk patients were female, aged between 12-18, departments of gynecology/obstetrics, general surgery, or ophthalmology. Higher incidence was found among adults using patient controlled anesthesia (PCA) and children using Opioids drugs. The risk of PONV was reduced when combined prescriptions with antiemetic drugs, such as Dexamethasone, Zofran, and Kytrill, in some patient groups. The effects of PONV on medical consumptions during hospitalization were also examined. Elevations of total medical expenses, and total drug expenses were found between PONV cases and their matched controls, particularly on Propofol users, TIVA users, patients in department of general surgery, patients aged 61-70, overweight patients, and physicians practicing less than 10 years. Discussion: The predictive model constructed by the above mentioned risk factors was helpful in identification of high risk patients on PONV so that prevention countermeasures could be early applied. Moreover, this identification of high risk group on PONV offers clues for constructing clinical guidelines for surgical patient management. The benefits of such management strategy can be found in both medical quality improvements and cost containments. In addition, the patient safety can be assured with the clinical decision rules. References: 1. Darkow T, Gora-Harper ML, Goulson DT, Record KE. Impacts of antiemetic selection on postoperative nausea and vomiting and patient satisfaction. Pharmacotherapy. 2001;21:540-8. 2. Forrester CM, Benfield DA, Matern DA, Kelly JA, Pellegrini JE. Meclizine in combination with ondansetron for prevention of postoperative nausea and vomiting in a high-risk population. AANA J. 2007; 75:27-33. 3. Gan TJ, Meyer TA, Apfel CC, et al. Society for ambulatory anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007;105:1615-28. 4. Karlsen KL, Persson E, Wennberg E, Stenqvist O. Anaesthesia, recovery and postoperative nausea and vomiting after breast surgery. A comparison between desflurane, sevflurane and isoflurane anaesthesia. Acta Anaesthesiol Sacnd. 2000;44:489-93. 5. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs. 2000;59:21343. 6. Murphy MJ, Hooper VD, Sullivan D, Clifford T, Apfet CC. Identification of risk factors for postoperative nausea and vomiting in the perianesthesia patient. J Perianesth Nurs. 2006;21:377-84. Funding disclosure: Nothing to disclose. Personal conflicts of interest disclosure: Nothing to disclose. A106 ANTICEPHALGIC PHOTOPROTECTIVE PREMEDICATED MASK: A REPORT OF A SUCCESSFUL STUDY OF A TREATMENT FOR MIGRAINE AND/OR TENSION HEADACHES M. Hyson Neurology, University of Nevada, Las Vegas, NV, USA Objectives: This study was performed to determine the efficacy of an anticephalgic photoprotective mask in conjunction with a topical medication containing bryonia and rhus toxicodendron in the treatment of migraine and/or tension headache. Background: Many clinicians are seeking headache treatment modalities with improved safety profiles. A premedicated mask would serve not only as a delivery system for benign topical medication, but simultaneously provide photorelief and exert external pressure which may alleviate vascular headaches by collapsing painfully distended extracranial arteries and reducing peripheral sensitization. Methods: Thirty-three patients were given masks and tubes of topical medication containing the bryonia and rhus toxicodendron. They were instructed to apply the medication to their frontalis and/or temporalis regions in the event they should suffer a headache and apply a photoprotective mask. Furthermore, they were instructed to take their usual oral or parenteral medications if required for the relief of the headache. They subsequently filled out forms rating the degree of relief which they attributed to the topical medication and the mask using a 0-10 scale. At the interview following the completion of their participation in the study, the patients were also simply asked if this form of treatment helped or not. Results: Thirty out of 33 patients stated the medication and the mask were effective over and above the normal degree of relief they were receiving from their oral and/or parenteral medications. This study demonstrated a significant efficacy rate (91%) in the treatment of migraine and/or tension headache with the anticephalgic mask in conjunction with a topical cream containing bryonia and rhus toxicodendron. Conclusions: This study demonstrated a significant efficacy rate in the treatment of migraine and/or tension headache with the anticephalgic mask in conjunction with a topical cream containing bryonia and rhus toxicodendron. A107 ULTRASOUND-GUIDED ROOT/TRUNK (INTERSCALENE) BLOCK FOR HAND AND FOREARM ANESTHESIA 1 1 2 1 1 1 1 1 S. Madison , J. Humsi , V. Loland , P. Suresh , N.P. Sandhu , M. Bishop , M. Donohue , D. Nie , E. 1 1 Furgeson , B. Ilfeld 1 2 Anesthesiology, UC San Diego, San Diego, CA, Anesthesiology, University of Washington, Seattle, 3 WA, UC San Diego, San Diego, CA, USA Introduction: Historically, the anterolateral interscalene block—deposition of local anesthetic adjacent to the brachial plexus roots/trunks—has been used for surgical procedures involving the shoulder. The resulting block frequently failed to provide surgical anesthesia of the hand and forearm, even though the brachial plexus at this level included all of the axons of the upper extremity terminal nerves. However, it remains unknown whether deposition of local anesthetic adjacent to the 7th cervical root or Inferior trunk—now possible using an ultrasound-guided technique—results in anesthesia of the hand and forearm. Materials and methods: Using ultrasound guidance and a needle-in-plane posterior approach, a Tuohy needle was positioned with the tip located between the deepest and next-deepest visualized brachial plexus root/trunk, followed by injection of mepivacaine 1.5% (Figure 1). Grip strength and the tolerance to cutaneous electrical current in five terminal nerve distributions were measured at baseline and then every 5 minutes following injection for a total of 30 minutes. The primary endpoint was the proportion of cases in which the interscalene nerve block resulted in a decrease in grip strength of at least 90%, and hand and forearm anesthesia (tolerance to >50 mA of current in all 5 terminal nerve distributions) within 30 minutes. The primary hypothesis was that a single-injection interscalene brachial plexus block produces a similar rate of anesthesia of the hand and forearm to the published success rate of 95% for other brachial plexus block approaches. [Figure 1] Figure 1. Ultrasound image of interscalene groove with needle position (arrow) and local anesthetic spread (asterisks) around the deepest-visualized neural element. Results: Of 55 subjects with blocks placed per protocol, all had a successful block of the shoulder as defined by inability to abduct at the shoulder joint. Thirty-three subjects had measurements at 30 minutes following local anesthetic deposition, and only 5 (15%) of these subjects had a surgical block of the hand and forearm (p< 0.0001; 95%CI: 6-33%). We therefore reject the hypothesis that the interscalene block as performed in this study provides equivalent anesthesia to the hand and forearm compared to other brachial plexus block techniques. Block failures of the hand and forearm were due to inadequate cutaneous anesthesia of the ulnar (n=27; 82%), median (n=26; 78%), or radial (n=22; 67%) distributions; the medial forearm (n=25; 76%), and/or the lateral forearm (n=14; 42%). Failure to achieve at least a 90% reduction in grip strength occurred in 16 subjects (48%). [Figure 2] Figure 2. Sensory (measured by tolerance to cutaneous electrical current) and motor block (measured by grip strength) 30 minutes following local anesthetic injection. Discussion: This study did not find evidence to support the hypothesis that local anesthetic injected adjacent to the deepest brachial plexus roots/trunks reliably results in surgical anesthesia of the hand and forearm. References: 1. RAPM. 2009;34:60-3 2. RAPM. 2009;34:3-7. 3. RAPM. 2009;34:498-502. Funding: NIH GM077026, NIH UL1RR031980, UCSD CTRI and Department of Anesthesiology Personal conflicts of interest: Nothing to disclose. A108 A CATHETER-OVER-NEEDLE ASSEMBLY IMPARTS GREATER STABILITY AND REDUCED RISK OF LEAKAGE ON INTERSCALENE CATHETERS COMPARED TO TRADITIONAL CATHETER ASSEMBLIES V.H.Y. Ip, B.C.H. Tsui Department of Anesthesia and Pain Medicine, University of Alberta, Edmonton, AB, Canada 1 Introduction: Continuous peripheral nerve blocks are susceptible to a number of complications, including leakage from the catheter insertion site. We recently reported a case where the leakage 2 from a traditional interscalene catheter threatened to contaminate the sterile surgical field. Removal and replacement with a “catheter-over-needle” (CON) assembly successfully overcame this problem. In this study, we hypothesized that interscalene CON assemblies are more stable and less prone to leakage at the insertion site compared to conventional catheter-through-needle (CTN) design. Material and methods: Following institutional ethics approval and informed consent, patients scheduled for shoulder surgery or proximal humerus surgery were randomized into control and study groups. Control group patients received an ultrasound-guided interscalene catheter using the traditional catheter insertion technique. A 13-6 MHz high frequency linear probe was used to identify the brachial plexus, and a 19G Tuohy needle was inserted in-plane in a lateral-to-medial direction between the C5/6 or C6/7 roots. Following hydrodissection with dextrose 5% in water (D5W) and 25mL of local anesthetics, a 20G catheter was inserted through the needle. The catheter was secured to the patient following needle withdrawal. Study group patients underwent a similar procedure except that a 21G x 95 mm catheter-over-needle unit was directed in a lateral-to-medial approach between the C5/C6 or C6/7 roots. Following hydrodissection with D5W and 25mL of local anethetics, the needle was removed, and an inner catheter was inserted into and Luer-locked to the outer catheter (Figure). [CON assembly with the inner and outer catheter] Both the inner and the outer catheter were in situ and secured to the patient as described above. The incidence of leakage and dislodgement/remanipulation of the catheter was recorded. Results: Fifteen patients were recruited for the study: 4 CTN; 11 CON. All CTN patients experienced leakage around the perineural catheter. One CTN (25%) migrated out on postoperative day one, and two CTNs (50%) required fortification with gauze to address leakage. One CTN (25%) was removed pre-operatively due to excessive leakage. In contrast, none of the CON patients experienced leakage around the catheter, and none required catheter remanipulation or fortification. Discussion: Our results suggest that interscalene CON catheters are considerably more stable and less prone to leakage compared to traditional CTN catheters. It should be noted that the number of patients in the CTN group was disproportionately small since the study was terminated after our surgical colleagues refused to operate on patients fitted with a CTN catheter due to the unacceptable risk of leakage contaminating the surgical site. References: 1. Ilfeld BM. Anesth Analg. 2011; 113: 904-25 2. Ip V et al. Can. J. Anesth. 2012; 59: 1125-9 Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest: The Pajunk MultiSet 211156-40E is modified and re-designed by Ban Tsui. Dr. Tsui also has a patent-licensing agreement with Pajunk. A109 THE IONOTROPIC AMPA TYPE GLUTAMATE RECEPTOR GLUA4 IS EXPRESSED IN EPIDERMAL KERATINOCYTES AND HAIR FOLLICLE BULGE CELLS 1 2 2 2 T. Irie , D.C. Ferri , M. Ruiz , D. Owens , J. Moron-Concepcion 1 2 2 3 Anesthesiology, Columbia University, NY, Anesthesiology, Dermatology, Columbia University, New York, NY, USA Introduction: Peripheral glutamatergic neurotransmission is important for pathogenesis of pain and itch1. Ionotropic glutamate receptors (iGluRs) include N-methyl-D-aspartate receptors (NMDARs), αamino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs), and kainate receptors 2 (KARs). Mechanosensitive nerve fibers of mammalian pelage hairs express NMDARs , but AMPAR /KAR expression in the epidermis is poorly described. Here we examine the expression of AMPAR and KAR in the epidermis of hairy skin and demonstrate unexpected expression of both in proliferative keratinocytes. Materials and methods: Dorsum skin of C57BL6 female mice was used in all the experiments. Immunohistochemical staining for GluA4 was observed using an Eclipse Ti Nikon confocal microscope. Based on the immunostaining pattern for GluA4, CD34+ keratinocytes were sorted using Fluorescence activated cell sorting (FACS). RNA from sorted and unsorted cells was extracted by a hybrid Trizol (Invitrogen)/RNeasy (Qiagen) method and used for OneStep RTPCR (Qiagen). GluA4 and 3 protein expression was assessed using western blotting. Results: In an experiment designed to explore AMPAR/KAR immunostaining in peripheral nerve fibers from hairy skin, we observed a prominent expression of GluA4 AMPAR subunit keratinocytes from the bulge of the hair follicle, generally delineating their surface. In order to confirm GluA4 expression, hair bulge keratinocytes were isolated by FACS as a6-integrin+/CD34+/Sca1- cells, analyzed by RTPCR for Gria4 transcript (encoding GluA4) and sequence verified. Furthermore, RTPCR confirmed keratinocyte expression of Gria3, Grik3, and Grik5, but not of Gria1 or Gria2. Western blots of mouse epidermis revealed immunoreactive bands for GluA4 (50kDa) and GluA3 (50 and 100 kDa), but not for GluA1 or 2. Grik3 or Grik5 were not assessed. Discussion: The results obtained here provide important insight in keratinocyte physiology and can have implications for regenerative medicine and hair growth research. stimulation of keratinocytes has been shown to elicit mechanical hyperalgesia and itch-related responses in mice5. An effect of AMPAR activation on keratinocyte calcium levels could be key to regulate the release of pruritogenic and pro-/antinociceptive mediators upon AMPAR timulation. Further research will assess the role of AMPAR/KAR in itch, hyperalgesia and epithelialization. References: 1. Larsson, M. and Broman, J. The Neuroscientist. 2012 2. Woo, S-H, et al. Development. 2012 3. Morris, R. J. In Keratinocyte Methods. 1994 4. Trempus, CS, et al. J Invest Dermatol. 2003 5. Caterina, M et al. Neuroscience 2012. Disclosures: None Grant support: NIH A110 BACTERIAL COLONIZATION OF CONTINUOUS PERIPHERAL NERVE BLOCK CATHETERS 1 2 H.K.P. Kalagara , V. Uppal , G. Haldane 3 1 2 Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA, Department of Anesthesia, London 3 Health Sciences Centre, London, ON, Canada, Department of Anesthesia, Hairmyres Hospital, East Kilbride, UK Introduction: Continuous peripheral nerve block (CPNB) catheters are being increasingly used for post-operative pain relief. The incidence of CPNB catheter colonization has been quoted to be 44%, if signs of local inflammation are present [1]. Colonization of CPNB catheters can lead to morbidity in the form of local infection, abscess formation or systemic infections [2]. We aimed to find the common types of bacteria that are responsible for colonization of CPNB catheters. Methods: After obtaining approval from our institutional clinical governance department, we carried out a retrospective analysis of our hospital acute pain services database. In our hospital, all the CPNB catheters (after removal) are routinely sent for microbiological analysis, if signs of local inflammation are present. The hospital database from June 2002 to December 2010 was investigated for all positive culture results. The type of bacteria and the site of catheter insertion were noted. Results: 976 CPNB catheter insertions were recorded in the database during the eight-year review period. 61 of these showed signs of local inflammation and therefore were sent for microbiological analysis. Twenty-two CPNB catheters had positive culture results. Five of these had two types of bacteria cultured, making the total number of bacteria isolated, twenty-seven. Common types of CPNB catheter inserted were fascia-illiaca, lumbar plexus, para-vertebral and transversus abdominis plane (TAP) block catheters. Table 1 shows the types of bacteria cultured from various CPNB catheters. Bacteria Staphylococcus epidermidis Number of cases isolated (percent) N=27 13 (48%) Methicillin-Resistant Staphylococcus aureus 5 (18%) Pseudomonas aeruginosa 3 (11%) Enterobacter cloacae 2 (7%) Proteus mirabilis 1 (4%) Klebsiella pneumoniae 1 (4%) Enterococcus faecalis 1 (4%) Bacillus 1 (4%) [Table 1] Discussion: Results of our study show that Staphylococcus epidermidis is commonest bacterium that colonizes the CPNB catheters followed by Staphylococcus aureus. The knowledge of bacteria commonly colonizing the CPNB catheters can be useful in guiding the antibiotic therapy should the infectious complications occur. References: 1. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005 Nov; 103(5): 1035-45 2. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology 2009 Jan; 110(1): 182-8 Funding disclosure: Only departmental funds were used for this study. No external funds were obtained Personal conflicts of interest disclosure: Nothing to disclose A111 RETROGRADE LARYNGEAL BLOCK: A NEW TECHNIQUE FOR AWAKE INTUBATION COMPARED WITH CONVENTIONAL REGIONAL AIRWAY BLOCK K. Karvandian, S. Sha`bani, J. Zebardast, E. Sadegzadeh 1 2 3 Anesthesiology and Critical Care Unit, Anesthesiology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Medical School, Tehran, Iran Introduction: Airway block is a useful method for providing patients comfort and safety during awake intubation. Retrograde laryngeal block is a new technique that blocks complete supraglottic and glottic area by introducing catheter retrograde from trachea to these regions. Methods and materials: This is a clinical trial conducted on two groups each containing 25 patients, who were candidate for awake intubation. The first group (A) underwent conventional method of airway block, by multiple injections of local anesthetic. The second group (B) underwent retrograde laryngeal block as a new method of regional airway anesthesia. In this method the catheter is inserted from cricothyriod membrane through a flexible guide wire, and then local anesthetic drug will be administered by direct vision of tip of the catheter by employing glidescope. The catheter has three separate orifices, each will stay on distinct area of either supraglottic and glottis area which can be adjusted at any level through these area that is considered to be blocked. Result: Both groups had hemodynamic stability during performing block. In group A we had two incidences of laryngospasm due to pain of multiple needle insertion(8%); in group B we had no incidence of laryngospasm (0%)(p=0.1). In group A we had 5 patients with partial airway block (20%) which needed further intervention during awake intubation but in group B all the cases had complete and perfect airway block(100%) (0.001). 22 patients comfort was better in group B (88%) with single injection than group A(13 patients) with multiple injections(52%) (0.005 ). Discussion: The advantage of this method is single injection and high quality of block performance in comparison with the other technique. And the most important advantage is that it can be conducted for the patients with neck pathologies that make conventional airway block impossible. Conclusion: This method is safe and practical for airway block. The unique advantage of this technique is that by remaining the catheter, we can provide continues airway block as long as we need to keep the patients intubated. This is of great benefit for the patients intubated in critical care unit . And the most important advantage of this method over conventional airway block is that, it can be applied in patients with neck pathologies that make conventional block impossible. A112 RETROSPECTIVE REVIEW OF EXPAREL IN INFILTRATION-TRANSVERSUS ABDOMINIS PLANE (I-TAP) BLOCKS IN HAND-ASSISTED NEPHRECTOMY AND COLORECTAL PROCEDURES R. Kesha, X. Jacobs, J. Hutchins University of Minnesota, Minneapolis, MN, USA Introduction: Infiltration into the transversus abdominis plane is a way to provide analgesia for either upper or lower abdominal surgery. However, a single shot may only provide analgesic coverage for up to 18 hours post-injection and patients may experience pain and discomfort beyond that 18 hour window. Exparel, a multivesicular formulation of bupivacaine, has been shown to provide analgesia 1 for up to 72 hours post-injection . Methods: This was a retrospective review of 20 patients, 12 hand-assisted nephrectomies and 8 hand-assisted colorectal procedures from October 2012 to December 2012. The infiltrationtransversus abdominis plane or i-TAP blocks were all placed bilaterally under ultrasound guidance in a pre-operative block area. The i-TAPs were subcostal for the hand-assisted nephrectomies and classic for the hand-assisted colorectal procedures. Each i-TAP injection consisted of 10 mL of 0.25% bupivacaine with epinephrine 1:200,000 injected first, immediately followed by a 20 mL 50:50 mixture of Exparel and normal saline for a total of 30 ml each side. Pain scores were obtained by on a daily basis. Patient´s were questioned daily about whether they felt relief or numbness in the area of their incision. Charts were also reviewed to obtain narcotic use, adverse events, and length of stay. Results: There was no difference in baseline characteristics between the two groups. The mean age was 49 years (SD 16.702). The mean pain score at rest was 2.3 (SD 1.78), 2.25 (SD 1.88), and 1.95 (SD 1.73) at 0-24 hours, 24-48 hours, and 48-72 hours post-injection. The mean pain score with movement was 5.25 (SD 2.12), 4.2 (SD 2.26), and 3.0 (SD 1.86) at 0-24 hours, 24-48 hours, and 4872 hours post-injection. The mean narcotic usage in fentanyl equivalents was 362.25 mcg (SD 261), 220.5 mcg (SD 189), and 121.75 mcg (SD 146) at 0-24 hours, 24-48 hours, and 48-72 hours postinjection. The mean length of stay was 3.5 days (SD 1.16). There was no significant difference in pain scores or opioid usage when the nephrectomy and colorectal procedures were compared. There were 4 patients with nausea and 2 patients developed a wound infection. All 20 reporting affirmatively for the first 48 hours that they felt numbness at their incision and had varying responses of when they started to notice a recession of numbness between 48-72 hours. There were no opioid or local anesthetic related adverse events. Discussion: These findings suggest that that the use of Exparel in i-TAP blocks is a useful adjunct to postoperative pain control up to 72 hours post-injection in those patients undergoing hand-assisted abdominal procedures. This study also suggests a favorable safety profile with no adverse events related to the use of Exparel in an i-TAP. Conflict of Interest: J. Hutchins is on speaker´s bureau for Pacira Pharmaceuticals. References: 1. Gorfine SR, Onel E, Patou G, Krivokapic ZV. Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Dis Colon Rectum. 2011;54:15521559. A113 DEXMEDETOMIDINE REDUCES DOSE REQUIREMENT OF THIOPENTONE SODIUM AND PENTAZOCINE, DECREASES POSTOPERATIVE PAIN AND REDUCES HAEMODYNAMIC FLUCTUATION S. Khanduja, A. Ohri, M. Panwar Anaesthesia, IGMC, Shimla, India Pain relief forms an important part of anaesthetic management today. Not withstanding the discovery of effective anaesthetic agents such as propofol and desflurane,they do not appear to have an impact on postoperative pain and nausea, two of the most common causes of delayed recovery and delayed 1 hospital discharge . Dexmedetomidine is a potent, highly selective α2- adrenoceptor agonist. We evaluated dexmedetomidine in anaesthetic practice for its sympatholytic, haemodynamic stabilizing, and analgesic and anaesthetic sparing properties. To study assess the role dexmedetomidine in reducing dose of sodium thiopentone ,analgesic requirement and decrease in post operative side effects. Sixty patients of age between 20-65 years, weight 47-70 kg, irrespective of sex for laparoscopic cholecystectomy under general anaesthesia were included in this single blinded randomized parallel-group study. The patients were randomly allocated to two groups, Group-A and Group-B each having 30 patients. Patients who had anemia , used long-term medications or use of any medication within 1 week before surgery , history of any chronic disease, history of drug abuse, consumed 30 gm of alcohol daily and abnormal preoperative electrolyte concentrations were excluded from study. Patients in Group-A received an infusion of normal saline, whereas Group-B patients received dexmetetomidine by adding 200 microgram of the compound to 38 ml normal saline making a total volume of 40 ml in microdrip set.. Infusion was started at the rate of 0.5microgram/kg/hr at 30 min before induction and 0.6microgram/kg/hr thereafter till the end of surgery.. Induction doses of Sodium thiopentone, analgesic/opioid requirement, post intubation haemodynamic response, haemodynamic fluctuations and recovery of the patient were noted. Requirement of thiopentone sodium in males, females and all patients decreased significantly from 3.69±0.23 mg/kg, 3.92±0.324 mg/kg and 3.88±0.318 mg/kg to 2.76±0.467 mg/kg, 2.55±0.184 mg/kg and 2.59±0.267 mg/kg respectively. Requirement of pentazocine also decreased significantly from 30±5.37 mg, 29.3±4.08 mg and 29.4±4.27 mg to 23.5±6.12 mg, 16.5±1.77 mg and 17.9±4.13 mg respectively. In the control group, 9 patients (3 males and 6 females) had complained of post- surgical pain. In the test (Dexmedetomidine) group of 30 patients, 4 (13.3%) complained of post-surgical pain. The most significant finding is that dexmedetomidine significantly decreased fluctuation in pulse rate/min (.P maxmin ) from 34.8 ± 8.98 to 18.7 ± 6.87, Similarly, values of variation in mean arterial pressure (MAP maxmin ) decreased significantly from 35.6 ± 11.3 to 19.97 ± 6.73(mmhg). Though, the post intubation pulse (PIP) and post intubation mean arterial pressure ( PIMAP) increased with respect to Pulse30 (PIP-P30) and MAP30 (PIMAP-MAP30), but dexmedetomidine treatment of the patients undergoing surgery significantly decreased this increase in pulse rate and mean arterial pressure.In short, dexmedetomidine reduces dose of thiopentone, pentazocine requirement and decreases post operative pain. Moreover, the fluctuation in pulse rate and mean arterial pressure narrowed down. 1- (Gold et al, 1989.). A114 COMBINATION FEMORAL NERVE BLOCK AND MULTIMODAL ANALGESIA REDUCES HOSPITAL LENGTH OF STAY IN PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY M.R. King, J. Paterno, E.A. Jacob, A.A. Freiberg, R.G. Peloquin, L. Warren, P. Stefanovich, M. Gargarian, K.H. Fleischmann 1 2 Department of Anesthesia, Critical Care and Pain Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA Introduction: Both femoral nerve block and multimodal periarticular injections have been shown to improve pain control following total knee arthroplasty. However, there is less data available on the effect on recovery and hospital length of stay. We investigate length of stay reduction following one surgeon's introduction of preoperative multimodal oral analgesics and femoral nerve block, and intraoperative multimodal injection. Materials and methods: Seventy patients who underwent unilateral total knee arthroplasty by a single surgeon (AAF) at Massachusetts General Hospital in 2010 and 2012 were randomly selected and retrospectively enrolled in the study. Patients who underwent surgery in 2010 prior to this surgeon's utilization of combined femoral nerve block and multimodal therapy were in the control group (n=34) and patients who had been operated upon in 2012 and received femoral nerve block and multimodal therapy were in the test group (n=36). Patients in the control group received either spinal or general anesthesia for surgery followed by oral and intravenous pain medications postoperatively. Patients in the test group received general or spinal anesthesia with standard postoperative pain management. They also received the following: celecoxib 400 mg, oxycodone continuous release 10-20 mg, and acetaminophen 975 mg po preoperatively, ultrasound-guided femoral block with 20 mL of 0.2% ropivacaine with 1:400,000 epinephrine, and a periarticular injection of a multimodal mix consisting of 30 mg ketorolac, 0.5 mg epinephrine, 0.08 mg clonidine, and 246.25 mg ropivacaine mixed in 100 mL normal saline intraoperatively. Statistical calculations were performed with two-tailed, unpaired t-tests. Results: Mean hospital length of stay was reduced in the entire test group compared to the entire control group (2.7 versus 3.3 days, p=0.003). When analyzed by intraoperative anesthetic, the difference between patients receiving spinal anesthesia with combination therapy (n=19) versus those receiving spinal alone (n=17) was even greater (2.3 versus 3.2 days, p< 0.0001). Patients receiving general anesthesia with combination therapy (n=19) saw a trend but no significant decrease in length of stay when compared to those not receiving combination therapy (n=17; 3.1 versus 3.4 days, p=0.25). [Hospital Length of Stay (Days)] Discussion: In this retrospective study, spinal anesthesia plus combination femoral nerve block and multimodal analgesic therapy significantly reduced hospital length of stay. Prospective data and larger sample sizes are needed to confirm these findings. References: 1. Allen HW, et al. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesthesia and Analgesia, 1998;87(1):93-97. 2. Venditolli PA, et al. A multimodal analgesia protocol for total knee arthroplasty: a randomized, controlled study. The Journal of Bone & Joint Surgery, 2006;88(2):282-289. 3. Wang H, et al. The Effect of Single-Injection Femoral Nerve Block On Rehabilitation And Length of Hospital Stay After Total Knee Replacement. Regional Anesthesia & Pain Medicine, 2002;27(2):139144. Funding and COI: none A115 IS EPIDURAL-PCA ANALGESIA NECESSARY FOR A THIRD DAY POST CESAREAN SECTION PAIN C. Kloepping, S. Cohen, S. Shah, S. Mungekar, A. Mohiuddin, A. Solina, C.W. Hunter Anesthesiology, Robert Wood Johnson University Hospital - UMDNJ, New Brunswick, NJ, USA Introduction: Our practice has been to provide epidural-PCA ropivacaine 0.025% with fentanyl 3 mcg/ml & epinephrine 1 mcg/ml for most of our post cesarean section (C/S) patients for 48 hrs. Very often, patients requested to continue this treatment for another extra day. rd Method: We determined if epidural-PCA analgesia is necessary for 3 day post C/S. Following IRB approval 112 p'ts who received epidural-PCA for post C/S pain for 48 hrs were included. The patients were given the option to continue this treatment for 72 hrs or to discontinue the treatment at 48 hrs and receive P.O. oxycodone 5 mg + acetaminophen 325 mg tabs along with ibuprofen 400 tab every 4 hrs PRN. Two groups were identified: G I: 78 p'ts preferred to continue the epidural-PCA treatment; G II: 34 p'ts preferred to discontinue the epidural-PCA treatment. Values are mean±SD. Results: The groups did not differ with age, weight, height or parity. The p'ts in GI received epidural infusion rate of 11.7 ± 7.0 PCA attempts of 24 ± 41 & PCA dose of 13 ± 13 ml. In G II 26 p'ts (76.5%) regretted their decision to discontinue the epidural-PCA treatment at 48 hrs. Overall satisfactions of the pain treatments were 9.3 ± 1.6 & 7.6 ± 2.3 (p< 0.00001) for G I& II respectively. Pain (rest at Pain(ambulation Pain(cough 72 hrs) at 72 hrs) at 72 hrs) Sedation Nausea Pruritus Group I 1.3 ± 2.0 2.5 ± 2.3 3.8 ± 2.8 7 (9%) 5(6%) 23(29%) Gropup II 2.7 ± 2.6* 4.2 ± 2.9* 5.2 ± 3.0** 13(38%)* 5(15%) 1(3%)^ G I>II: *p<0.005, **p<0.03; ^G II<I, p<0.005. [Table I] Conclusions: During 48-72 hrs following C/S most p'ts still complained of pain & requested to continue the epidural-PCA ropivacaine-fentanyl-epinephrine which provided excellent analgesia with minimal side effects. A116 TX360™: A NON-INVASIVE TECHNIQUE FOR SPHENOPALATINE GANGLION NERVE BLOCK IN THE TREATMENT OF TRIGEMINAL NEURALGIA K.D. Candido, R. Sauer, L. Chupatanakul, N.N. Knezevic 1 2 Anesthesiology and Pain Medicine, Advocate Illinois Masonic Medical Center, Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Introduction: The sphenopalatine ganglion, located in the posterior part of the middle nasal turbinate, is involved in pain associated indirectly with trigeminal neuralgia (TGN). Local anesthetic therapeutic treatment can be provided by using a cotton-tip-applicator approach, hard palate injection or invasive surgical procedures which might potentially result in development of permanent nerve damage. Objective: The purpose of this pilot study was to present a novel non-invasive treatment of facial pain in patients diagnosed by independent neurologists as having TGN, with the nasal applicator™ for sphenopalatine ganglion nerve block (SPGB). [Figure 1] Material and methods: After IRB approval, patients were evaluated for pain using a numeric rating scale (NRS), modified brief pain inventory, Patient Global Impression of Change (PGIC), and patient satisfaction. The Tx360™ Nasal Applicator with 1 mL of 0.5% bupivacaine with freshly added 1:200,000 epinephrine were used to perform bilateral SPGB. Pre-procedural evaluations were repeated post-block at 15 minutes, 30 minutes, and every week up to 28 days post-procedure. Results: Three female patients, ages 15, 18 and 43 presented with TGN. The average baseline NRS score was 7 at rest and 9/10 with mastication. All patients had improvement during the first 15 minutes with an average NRS score 2, which persisted to the first day post-procedure. At the end of the 28 days the average daily pain increased only up to 4 on the NRS. All three patients were completely satisfied, and the PGIC status was significantly improved on average. One patient developed minimal bleeding from the nose on the first day which stopped spontaneously in < 5 minutes. Conclusion: SPGB with Tx360™ provided clinically significant pain relief with minimal complications in three patients with documented TGN. Modest pain increase during the 28 day follow-up may indicate the need for repeating the procedure, and evaluating the efficacy of this technique. An additional seven patients are being screened to assess the technique and gauge its effectiveness statistically. A117 PATIENT SATISFACTION WITH GENERAL VERSUS REGIONAL ANESTHESIA FOR ARTERIOVENOUS ACCESS SURGERY IN PATIENTS WITH END-STAGE RENAL DISEASE M. Koronfel, P. Loubser, M. Elhakim, B. Marasigan, S. Feng Zhou, K. Charlton-Ouw, A. Azizzadeh 1 2 Anesthesiology, Cardiothoracic and Vascular Surgery, The University of Texas Medical School, Houston, TX, USA Introduction: Patients with end-stage renal disease (ESRD) undergoing arteriovenous access procedures for hemodialysis present multiple challenges for anesthesiologists. (1) Regional anesthesia (RA) has several theoretical advantages over general anesthesia (GA) and may impact the actual surgical outcome. (1) However, delivery of effective RA for these procedures requires planning, additional equipment and education. In addition, anesthetic outcome and patient satisfaction also require observation, to ensure that quality of care is maintained. In 2010, a RA service for upper extremity AV access procedures was initiated in this institution (interscalene or supraclavicular technique). The purpose of this study was to review the initial experiences and patient satisfaction with this new service; in addition, RA was compared with GA. Materials and methods: This retrospective study was reviewed and approved by the Institutional Committee for Protection of Human Subjects. A 9 item survey was conducted by PACU nursing staff on all patients under- going GA and/or RA during routine follow-up on postop Day 1. The survey addressed side-effects, satisfaction with anesthetic, duration of recovery and time taken to initiate activities of daily living, and used scores, Likert scales and narrative descriptors. Where indicated, the student t-test was used to compare groups using a p value < 0.01 for statistical significance. Results: Sixty six patients were studied, consisting of 36 undergoing GA and 30 RA. Complete assessments could not be completed in 13 and 3 patients in the GA and RA groups, respectively. All stated that they would choose the anesthetic again. Regional block duration was 4.7 ± 0.4 hours. There were no side effects in the RA group. The GA group rated their experience significantly lower (2.2 ± 1.1); seventeen percent of patients stated that they would not choose the same anesthetic again, and 30% experienced side effects ranging from drowsiness to nausea. However, time to resume activities of daily living was not significantly different between groups. [Patients' experiences with regional anesthesia] Conclusions: The findings of this retrospective study demonstrated that patients undergoing RA experienced significantly better postoperative pain control well beyond the PACU, compared to the GA group. Patients undergoing RA reported a more satisfactory perioperative experience compared to the GA group. Side effects following GA were also significantly higher than the RA group. This is the first study to demonstrate advantages of regional over general anesthesia from a quality of care standpoint. However, this study was retrospective in nature, and certain variables may have been operative such as non-randomization of technique and lack of blinding. Therefore, a prospective study is indicated to address these variables. In addition, this study did not examine surgical factors, such as duration and outcome of surgery, and correlate these with type of anesthetic, which is a secondary area for study. References: Malinzak EB, Gan TJ: Regional anesthesia for vascular access surgery. Anesth Analg 2009;109(3):976-80. A118 REAL-TIME ULTRASOUND GUIDED APPROACH FOR SPINAL ANESTHESIA M. Koski, A. Maheshwari, L. Mounir-Soliman, A. Kurz, D.I. Sessler, H. Elsharkawy M.D. General Anesthesiology, Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA Introduction: Spinal anesthesia can be challenging in patients with difficult anatomy. Pre procedural ultrasound has been shown to have promising results (1); however, spinal anesthesia performed with real time ultrasound guidance has not been studied in patients with presumed difficult anatomy. Methods: Fourteen patients with presumed difficulty for spinal blockade undergoing elective total joint arthroplasty of the lower extremity were selected for ultrasound-guided block between April, 2012 and August 2012 after IRB approval and informed consent. Patients with any one of the following were 2 included; age ≥ 55, BMI > 40 kg/m , or a history of scoliosis. Each spinal block was performed by 1 of 5 staff anesthesiologists who had limited experience with ultrasound-guided neuraxial anesthesia, yet were well experienced providing peripheral nerve blocks via US. The spinal blocks were performed in the sitting position with standard ASA monitors in place, while 1-2 mg of IV midazolam was administered. The blocks were done practicing standard sterile technique with a curved-array 2-5 MHz transducer. The lumbar spine was visualized in both midline and paramedian views. The locations of the interlaminar spaces were identified by visualizing the ligamentum flavum-dura mater complex and the posterior aspect of the vertebral body (Figure 1). Paramedian needle insertion was guided in real time by ultrasound imaging. The scanning of each patient's anatomy was standardized, including four views and the quality of visualization of the needle tip evaluated by the operator on a scale of excellent to no visibility at all. Outcomes were reported with concurrent with patient care as reported below. Results: The average time to perform the block was 4:15 minutes +/- 0.09 seconds. This time did not correlate with age, sex or BMI. Operator difficulty rating correlated linearly with time to perform the block but did not correlate well with patient characteristics such as, BMI and age. All patients rated their experience 5/5 (extremely satisfied), except for one (3/5). Vertebral level based on landmark and palpation was wrong 35.7% of the time as compared to level determined by ultrasound visualization scanning up from sacrum. Depth of the dura complex as determined by ultrasound had a large variability and did not correspond well with actual depth as measured by needle length inserted to get CSF. There were no cases of post dural puncture headache, back pain or infection. Discussion: Real time ultrasound is a feasible technique for spinal anesthesia in patients with presumed difficulty. The data from this study can be used to plan a randomized controlled study to evaluate the comparative effectiveness of real time ultrasound guidance as compared to the standard landmark based technique in patients with difficult spinal anatomy. References: 1. Chin, K.J., et al., Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology. 115(1): p. 94-101. Funding: Funded internally by the Department of General Anesthesia and Outcomes Research, Cleveland Clinic. [Figure 1: Ultrasound image of L3 - L4 spinal block] A119 ENHANCED RECOVERY FOR KNEE AND HIP ARTHROPLASTY: HAS 2% HEAVY PRILOCAINE A PLACE - OUR EXPERIENCE M. La Malfa, B. Korba, B. Hargitai, P. Kocsis, B. Mavrodiev, J. Hamza, S. Dinev, O. Kovacs, K. Alexa, L. Levy, C. Flower, M. Jacob 1 2 Anaesthetics, Physiotherapy, UK-SH, Emersons Green NHS Treatment Centre, Bristol, UK Background and aims: Enhanced recovery protocols do improve the quality of care and the clinical outcomes for the joint replacement patients.The aim of this audit was to evaluate the impact of the use of spinal 2 % heavy prilocaine on our multidisciplinary recovery program in terms of pain management, early mobilisation and discharge from the hospital. Methods: 160 patient were included ( 77 THR and 83 TKR ), Asa 1,2 and stable 3, age was not an exclusion criteria. The anaesthetic was standardised, so was the peri and post operative drug and fluid management . 55 TKR and 34 THR patients recieved spinal H. prilocaine, 28 TKR and 23 THR recieved H. marcaine. The parameters considered were patient´ s time of first mobilisation,bromage score, average pain score, ponv,diziness/fainting, knee and hip range of movement, wound oozing, hospital length of stay. All patients received our enhanced recovery protocol. Results: 67 patients were male, average age was 69.38. Success of early mobilisation was 63% in the Prilocaine group, 56.3 % in the Marcaine group. At first mobilisation, systolic BP was below 100mmhg in only 28% of the patients in the prilocaine group vs 40% within the marcaine group. Nausea, diziness and ponv were similar within the two groups so as the average pain score (VAS). Conclusions: 2% Heavy prilocaine permits early mobilisation and it is reccomended in patients with several co-morbidities where stable peri-operative haemodinamic status is desirable. Patient satisfaction is extremely high and hospital lenght of stay reduced References: 1. Br J Anaesth. 2010 May;104(5):582-6. Urinary retention after spinal anaesthesia with hyperbaric prilocaine 2% in an ambulatory setting.Kreutziger J, Frankenberger B, Luger TJ, Richard S, Zbinden S. 2. Br J Anaesth. 2011;106(2):183-188. Spinal Anaesthesia for Ambulatory Arthroscopic Surgery of the Knee: A Comparison of Low-dose Prilocaine and Fentanyl with Bupivacaine and FentanylA. S. Black, G. N. Newcombe, J. L. Plummer, D. H. McLeod, D. K. Martin 4. Acta Orthop. 2011 Oct;82(5):577-81. Enhanced recovery program for hip and knee replacement reduces death rate. Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, 5. Arch Orthop Trauma Surg. 2012 Aug;132(8):1153-63. Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. den Hertog A, Gliesche K, Timm J, Mühlbauer B. A120 PREPUNCTURE SCANNING FOR THORACOLUMBAR PARAVERTEBRAL BLOCKS 1 1 2 1 1 1 1 N.C.K. Lam , J. Higgins , E. Mariano , T.R. Petersen , N. Gerstein , E.E. Szabo , F. Jaime , N. 1 Doran 1 Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, 2 NM, Department of Anesthesiology, Stanford University, Stanford, CA, USA Introduction: Inguinal hernia surgery can result in moderate to severe pain, which affects daily 1 activities. It has been suggested that inadequate pain control in the postoperative period is 2 associated in the development of chronic groin pain. When comparing paravertebral block to combined peripheral nerve blocks and local infiltration for postoperative analgesia, it has been shown that patients with paravertebral blocks experienced superior dynamic pain control and had reduced postoperative nausea and vomiting in the recovery 3 area. Ultrasound has been used for pre-puncture scanning for thoracolumbar paravertebral regional 4 anesthesia resulting in improved transverse process depth estimation. However, there are no studies investigating if the use of ultrasound reduces post-operative analgesic requirements. Methods: After IRB approval, all patients 18 years and older who underwent unilateral hernia surgery repair with a T11-L2 paravertebral block within the period from March 1, 2011 through August 31, 2012 at a single outpatient surgical center were included in the study. Patients who had a documented history of opioid abuse or were on chronic opioid therapy during the preceding 3 months were excluded. This criteria resulted in data collection of 143 surgeries from 143 patients. Equianalgesic opioid conversions were performed to an equivalent dosage of intravenous morphine 5 using standard conversion guidelines. Patients who underwent prepuncture ultrasound scan for lumbar paravertebral blocks were compared with patients where landmark based lumbar paravertebral blocks were used. The primary endpoints measured between the two groups were differences in total narcotic and postoperative opioid requirements and differences in preoperative versus postoperative pain scores. Results: Postop Preop pain pain Median Median (IQR) (IQR) Intraop Preop Total Total Narcotic Narcotic Median Median (IQR) (IQR) Postop Total Narcotics Median (IQR) Total Narcotics Median (IQR) Ultrasound 0(0,0) prepuncture 2(0,5) 10(10,10) 0(0,10) 0(0,3.1) 16.3 (10,20.6) Landmark 0(0,1) 2(0,5) 10(10.10) 5(0,10) 2.5(0,7.5) 20 (11,24) P value 0.23 0.72 0.94 0.24 0.27 0.07 [Results of Prepuncture Scan vs Landmark technique] Discussion: There is a tendency for patients with landmark based paravertebral blocks to need more analgesics intraoperatively, postoperatively, and in total, but none are significant with this 143-patient sample. Prepuncture ultrasound in paravertebral blocks for inguinal hernia does not reduce postoperative analgesia requirements References: 1) Callesen T, Bech K, Nielsen R, Andersen J, Hesselfeldt P, Roikjaer O et al. Pain after groin hernia repair. Br J Surg 1998; 85: 1412-1414 2) Aasvang EK, Gmaehle E, Hansen JB, Gmaehle B, Forman JL, Schwarz J et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology 2010; 112: 957 - 969 3) Klein SM, Pietrobon R, Nielsen KC, Steele SM, Warner DS, Moylan JA et al. Paravertebral somatic nerve block compared with peripheral nerve blocks for outpatient inguinal herniorrhaphy. Reg Anesth Pain Med 2002; 27: 476 - 480. 4) Ilfeld, Brian M., Vanessa J. Loland, and Edward R. Mariano. "Prepuncture Ultrasound Imaging to Predict Transverse Process and Lumbar Plexus Depth for Psoas Compartment Block and Perineural Catheter Insertion." Anesthesia & Analgesia 110.6 (2010): 1725-728. 5) Gordon, Debra B., Karen K. Stevenson, Juliann Griffie, Sandy Muchka, Cathy Rapp, and Kate Ford-Roberts. "Opioid Equianalgesic Calculations." Journal of Palliative Medicine 2.2 (1999): 209-18. A121 2% HEAVY PRILOCAINE FOR PRIMARY LOWER LIMB JOINT ARTHROPLASTY IN AN ENHANCED RECOVERY SETTINGS B. Lassota-Korba, M. La Malfa, J. Hamza, J. Va Faye, C. Flower, B. Hargitai, B. Mavrodiev, L. Levy, P. Kocsis, S. Dinev Anaesthetics, United Kingdom Specialist Hospitals, Bristol, UK Introduction: Lower limb total joint arthroplasty is one of the most commonly performed orthopaedic surgical procedures worldwide and enhanced recovery protocols in a multidisciplinary settings have been introduced to maximise benefits of early mobilisation (such as VTE), reducing anaesthetics side effects/complications, minimising post operative pain and reducing length of stay in this cohort of patients. 2% Heavy Prilocaine has recently been introduced in the United Kingdom. It has been claimed that it confers a shorter duration of action when used in spinal anaesthesia. We have devised a study in order to ascertain the safety and effectiveness in use of heavy prilocaine as part of our existing enhanced recovery setting. We collected the data in order to establish the best approach in management of this group of patients, to analyse consequences and to set up the best possible patient management. Intra-operative feedback from surgeons was also sought to find any difficulties posed with regards to muscle tension during the surgery due to incomplete muscle relaxation. Material and methods: We evaluated 100 consecutive patients undergoing total hip or total knee replacement surgeries under spinal anaesthetic using combination of 2% heavy Prilocaine 50mg, Fentanyl 30 mcg and Morphine 150 mcg. We have implemented the standardized protocol and assessed the onset of and the resolution of the spinal block using the Bromage score, the time of first mobilization from surgery, PONV, pain, hemodynamic stability and intra-operative surgeon feedback score. We also collected data on post operative complications. Results: We have preliminarily analyzed 100 cases. The average age of patient was 70.53, the average ASA score was 1.71. The average time to reach the Bromage Score of 4 was 5.61 minutes. Average VAS score on day 0 was 0.18 out of 10, on day 1 was 1.72, on day 2 was 1.40. 23% of patients experienced transient mean BP drop of < 65mmHg during surgery when TCI Propofol sedation was used and in 16% a nominal single dose vasoconstrictor was used. PONV experienced was 7%, minor itching was noticed in 5% of patients. 63% of patients were mobilized on the day 0 within 6 hours from end of surgery and 94% on day 1. The average length of stay was 2.94 days (the range 1 - 4 days). There were no major post operative anaesthetic or orthopaedic complications or mortalities in a six month period. Discussion: Our results demonstrate that 2% Heavy Prilocaine is safe and contributes significantly to efficient and effective enhanced recovery of patients undergoing lower limb primary joint arthroplasty. In our multidisciplinary setting, patients undergoing joint arthroplasty had excellent clinical outcomes, shorter lengths of stay and minimal complications. A122 PREOPERATIVE CATASTROPHIZATION SCORE AS A PREDICTOR OF DYNAMIC ACUTE PAIN INTENSITY AFTER TOTAL KNEE ARTHROPLASTY (TKA) P.M. Lavand'homme, I. Grosu, E. Thienpont 1 2 Anesthesiology, Orthopedic Surgery, Cliniques Universitaires Saint Luc, Brussels, Belgium Background: Catastrophization is a negative mental set increasing pain intensity and emotional distress during painful stimulation (1). TKA a major but common orthopedic surgery is associated to severe postoperative pain (2). Because early mobilization is mandatory to successful rehabilitation after TKA, it might be of interest to target patients who will suffer more severe pain, particularly at movement. Material and methods: After IRB approval and informed consent, patients undergoing primary TKA filled in preoperatively the French version of original Sullivan's Pain Catastrophization Scale (PCS) with subscales of magnification (M PCS), rumination (R PCS) and helplessness (H PCS). A single surgeon performed all surgeries under standardized anesthesia protocole with postoperative multimodal analgesia. Postoperative pain scores were recorded from day1 to day7 (VAS 0-10) at rest (PAR) and for movement evoked pain (MEP). Statistical analysis used unpaired t-tests and Pearson's correlation, p< 0.05 was significant. Results: 94 patients were included, age 66±9 yrs, median PCS value 12 (IQR 5-20). For data analysis, patients were separated in 2 groups: high PCS >12 (n=45; value 19.5, IQR 14-30) and low PCS < 12 (n=49; value 5, IQR 3-9). High PCS patients had significantly higher postoperative pain at mobilization from day3 to day7 (figure expressing the increase of pain during mobilization, as MEP/PAR (2)). Preoperative PCS positively correlated with MEP at day7 (r=534;p=0.0004), as well as M PCS, R PCS and H PCS dimensions. H PCS also correlated with MEP intensity at day3 and day4. No correlation was found between PCS and PAR intensity. [Postoperative dynamic pain after TKA] Discussion: The results confirm that preoperative PCS value may be an interesting predictor of severe postoperative pain, specifically for pain during mobilization. Similar observation has already been reported for different procedures including major spinal orthopedic surgery (3). References: (1) Sullivan M et al, Clin J Pain 2001; (2) Srikandarajah & Gilron, Pain 2011; (3) Papaioannou M et al, Pain Med 2009. A123 TAP BLOCK FOR PERITONEAL DIALYSIS CATHETER PLACEMENT, REMOVAL, OR REVISION K. Lebak, K. Schroeder, M. Donnelly Department of Anesthesiology, University of Wisconsin, Madison, Madison, WI, USA Introduction: We evaluated the impact of a pre-operative transversus abdominis plane (TAP) block on the perioperative course in adult patients undergoing peritoneal dialysis (PD) catheter placement, removal, or revision at a university hospital-based ambulatory surgery center. We wanted to determine if a TAP block allowed us to reliably avoid general anesthesia (GA) and was effective in reducing postoperative pain scores, time to discharge from the recovery room (PACU), perioperative opioid use, and postoperative and postdischarge nausea and vomiting. Additionally, because a TAP block for PD catheter surgeries is not well described in the literature, we wanted to determine if there was an increased incidence of adverse events or unplanned admissions associated with this anesthetic technique. Materials and methods: We retrospectively evaluated all ambulatory patients who presented for PD catheter placement, removal, or revision and compared the perioperative course between patients who received a preoperative TAP block (TB) and those who had no tap block (NTB). All PD catheter patients from Jan 1, 2007-Sept 1, 2012 were identified through our billing service. A total of 110 adult patient surgeries (93 patients) were identified with 104 surgeries (90 patients) analyzed. Three patient charts, equaling 6 procedures, were unable to be located in a reasonable amount of time, thus were excluded from the analysis. Results: Forty-three surgeries were placement of catheters, 56 removal, and 5 revisions. Eight surgeries had a preoperative TAP block with 6 combined with sedation anesthesia (none converted to GA) and 2 received planned general anesthesia (due to laparoscopic technique in placing catheters). There were no adverse events in the TB group, but there was one unplanned admission for observation. There were no differences in age, gender, BMI, ASA score, preoperative opioid use, anesthesia time, total operating room time, surgery time, PACU time, Phase II time, or postoperative nausea and vomiting between the TB and NTB groups. There was a trend towards a significant difference in Phase II peak pain scores (p=0.08) and postoperative opioid use. Discussion: TAP blocks have been used successfully for pain control for a variety of surgeries. Varadarajan et al. described a TAP block combined with a rectus sheath block for peritoneal dialysis 1 catheter placement. To our knowledge this is the first report of TAP blocks used alone for PD catheter surgeries. Limitations of this study include an absence of randomization and a small number of TAP blocks. There was a potential for difference if more patients were studied namely in the TAP group. Importantly, there were no differences in anesthesia, total operating room, or surgery times between the two groups which can often be a concern of surgeons and thus a barrier to surgeons requesting regional anesthesia. References: 1. Varadarajan, Y and Balasubramaniyam, R. Ultrasound guided rectus sheath and transversus abdominis plane block (TAP) for continuous ambulatory peritoneal dialysis (CAPD) catheterization-our experience. Nephrol. Dial. Transplant. (2012) 27 (suppl 2): ii457-ii482. This article appears in: 49th ERA-EDTA Congress, May 24-27, 2012, Paris, France. Disclosure: There is nothing to disclose from any of the authors. A124 EFFECT OF SYRINGE SIZE ON OPENING INJECTION PRESSURES 1 2 2 1 3 4 E. Lin , C. Vandepitte , K. Buyse , J. Gadsden , I. Hasanbegovic , X. Sala-Blanch , P. Gautier 1 2 5 3 St. Luke's Hospital Center, New York, NY, USA, University Hospitals Leuven, K.U.L., Department 4 of Anesthesiology, Katholieke Universiteit Leuven, Leuven, Belgium, St. Luke's-Roosevelt Hospital 5 6 Center, Columbia University College of Physicians & Surgeons, New York, NY, USA, Institue of 7 Anatomy, University of Sarajevo, Sarajevo, Bosnia-Herzegovina, University Hospital Barcelona, 8 Barcelona, Spain, Clinique Ste Anne-St Remi, Brussel, Belgium 1 Introduction: High opening injection pressure (> 15 psi) can detect needle-nerve contact. However, the reliability of injection pressure monitoring to detect needle-nerve contact or impingement may be affected by syringe size. We hypothesized that monitoring of opening injection pressure (the pressure at which injectate is detected by US) is affected by the size of the syringe used for injection. Methods: After Ethics Committee approval (KU Leuven, BE), 22 gauge 50 mm needles (Stimuplex-A, B Braun, Inc) were inserted under US to contact the C5, C6 and C7 nerve roots in fresh frozen human cadavers. Hand-held injections were made using 3 different syringe sizes (5, 10, 20 mL) at a rate commensurate with typical clinical practice. Injections were made bilaterally at each of the above nerve roots. Opening injection pressure data were acquired with an in-line digital pressure recorder using a 60 ml syringe (10 ml/min), and injection halted when spread was detected. Results: A total of 48 injection measurements were made. The peak (opening) pressures at which injection commenced are displayed in the table. Opening injection pressures were similar regardless of syringe size (p>0.05), or method of injection (hand-held versus automated pump) (p>0.05). Automated Pump Injection Hand-Held Injections Syringe Size 5cc (n = 12) 10cc (n = 12) 20cc (n = 12) 60cc (n = 12) Cadaver 1 30.50 29.2 26.03 23.42 Cadaver 2 34.07 34.95 29.42 34.03 [Mean Peak Opening Injection Pressures (psi)] Discussion: The size of the syringe commonly used in clinical practice of PNBs did not significantly affect the monitoring of the open injection pressure. All injections with the needle-nerve contact resulted in injection pressures ≥20 psi, regardless of syringe size or method of injection. Our findings are thus consistent with the fluid mechanics described by Pascal's Law, where pressure exerted anywhere in a confined incompressible fluid system is transmitted equally throughout until the opening pressure is reached and injection begins. Pascal's Law also states that pressure remains constant throughout the syringe, needle and tubing until the flow of fluid begins, regardless of the syringe size, speed of injection or diameter of fluid passages. References: 1. Kapur, E., Vuckovic, I., Dilberovic, F., Zaciragic, A., Cosovic, E., Divanovic, K.-A., Mornjakovic, Z., Babic, M., Borgeat, A., Thys, D. M. & Hadzic, A. Neurologic and histologic outcome after intraneural injections of lidocaine in canine sciatic nerves. Acta anaesthesiologica Scandinavica 51, 101-7 (2007). A125 REGIONAL ANAESTHESIA - IS IT WHAT PATIENTS WANT? A PROSPECTIVE AUDIT OF PATIENT PREFERENCE AFTER AXILLARY BLOCK FOR HAND TRAUMA J. Mathers, D. Patel, A. Hayward Department of Anaesthetics, Royal Free Hospital, London, UK Introduction: As clinicians we often feel regional techniques are best for upper limb surgery as it 1 offers excellent analgesia, swifter theatre throughput and reduced costs for upper limb surgery . However, it is not always known what patients would prefer when given the choice of regional over general anaesthesia. Material and methods: 48 patients undergoing regional anaesthesia for corrective hand trauma surgery under axillary block with sedation were followed up the day after surgery by telephone to give feedback on their experience and also whether they would choose to have general or regional anaesthesia for the same surgery. All axillary blocks were performed by a single operator using a standardized technique with midazolam (max 4mg) and alfentanil (max 600mcg) IV sedation titrated to effect. Axillary blocks were performed awake with ultrasound and nerve stimulator guidance. At any point patients could refuse regional anaesthesia and choose a general anaesthetic. Results: None of the patients had previous experience of upper limb regional blocks. None of the patients requested a general anaesthetic. There were no block failures and no coversions to general anaesthesia or requirements for block top-ups. 29 patients had previously had general anaesthetics, of those only one would have preferred a general anaesthetic to a block. All 19 patients who had not had general anaesthetics preferred a regional technique. Overall 98% of patients prefer a regional technique. Discussion: Regional anaesthesia is known to increase theatre efficiency and provide optimal analgesia but to provide patient-centered care where possible we should provide the anaesthetic that patients prefer. Without prior experience patients can only make decisions based upon limited information. We have identified that patients prefer regional anaesthesia to general anaesthesia for hand surgery. References: 1. Horn J et al. Comparison of efficiency, recovery profile and perioperative costs of regional anaesthesia vs. general anaesthesia for outpatient upper extremity surgery. European Journal of Anaesthesiology 2007; 24: 557-559 Funding disclosures: No funding was received for this audit Personal conflicts of interest disclosure: Nothing to disclose A126 THE PERIOPERATIVE MANAGEMENT OF BILATERAL TOTAL KNEE ARTHROPLASTY PATIENTS: THE RESULTS OF THE CONSENSUS CONFERENCE ON BILATERAL TOTAL KNEE ARTHROPLASTY GROUP 1 1,2 1 1 1 S.G. Memtsoudis , O. Stundner , M. Mazumdar , M. Urban , A. Gonzalez Della Valle , L.A. 1 1 Poultsides , T.P. Sculco 1 Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell 2 University, New York, NY, USA, Department of Anesthesiology, Perioperative Medicine and Intensive 3 Care Medicine, Paracelsus Medical University, Salzburg, Austria, Division of Biostatistics and 4 Epidemiology, Department of Public Health, Department of Orthopedic Surgery, Weill Medical College of Cornell University, New York, NY, USA Introduction: Considerable controversy exists surrounding various aspects of simultaneously performed bilateral total knee arthroplasty (BTKA). Despite the notion that this procedure may be associated with increased risk of complications compared to a unilateral total knee arthroplasty (TKA), no consensus on appropriate patient selection and management among perioperativ clinicians exists. As this topic is of immediate importance to anesthesiologists taking care of this patient population, the purpose of this manuscript is to present the results of a recent meeting of the Consensus Conference on Bilateral Total Knee Arthroplasty Group, comprised of national experts, that examined various issues related to BTKA. Material and methods: After selection of a multidisciplinary group of experts in the fields of anesthesiology, orthopedic surgery, perioperative medicine and epidemiology, the major questions surrounding same stage BTKA were addressed by utilizing an extensive literature review and the modified Delphi process. The year-long process concluded with a meeting of participants and the formulation of consensus statements. Results: While more detailed consensus was reached on a number of topics, in brief, the consensus group agreed that physicians and hospitals should consider using conservative patient selection criteria in order to mitigate the increased risk for complications associated with same stage BTKA. Consideration should be given to the fact that BTKA is a more invasive and complex procedure compared to UTKA and perioperative assessment and management should reflect the higher level of acuity. If a patient is not deemed a candidate for same stage BTKA sufficient time should be allowed for the reversal of the physiological insult of surgery and recovery of organ systems between procedures. While in some cases orthopedic indications may favor BTKA, these indications should not override medical concerns, except in extremes of circumstances. In all cases of BTKA a thorough discussion with the patient about risks, benefits and alternatives should take place prior to proceeding with surgery. Discussion: Same stage BTKA poses specific challenges and a systematic approach to the management of patients should be taken in order to minimize complications. Careful patient selection and comprehensive perioperative care is important to minimizing perioperative risk. A127 THE EFFECT OF INTERSCALENE BRACHIAL PLEXUS BLOCK ON THE PULMONARY FUNCTION OF OBESE PATIENTS H. Monroe, M.S. Melton Anesthesiology, Duke University Medical Center, Durham, NC, USA Introduction: Interscalene block (ISB) of the brachial plexus is a regional anesthetic technique for shoulder surgery. A normal side effect is an ipsilateral hemidiaphragmatic paresis. Previous work in healthy, non-obese subjects demonstrated that this resulted in a 25% reduction in pulmonary function. Due to their baseline restrictive pathology, obese patients may be at greater risk for pulmonary impairment following ISB. The primary objective of this prospective cohort study was to evaluate the effects of ISB and associated transient hemidiaphragmatic paresis on the pulmonary function of obese patients, compared with a non-obese population. This study tested the hypothesis that obese patients have a larger decrease from baseline pulmonary function tests (FEV1 and FVC) compared with non-obese patients. Methods: Fifteen subjects presenting for ISB for elective shoulder surgery at the Duke Ambulatory Surgical Center (ASC) have been enrolled to date. Prior to ISB placement baseline data was obtained, including bedside FEV1 and FVC measurements in the sitting and supine position (handheld spirometer (Micro Medical, Kent, England), diaphragm function (assessed by ultrasound), and subjective symptoms of dyspnea (Borg dyspnea score). Ultrasound guided ISB was then placed. All measurements were repeated at 15 and 30 minutes after ISB placement, and again in the postanesthesia care unit (PACU). Normal BMI and obese groups were compared with exact chisquared tests for categorical values and 2-group t-tests for numeric measures. Comparisons between pre-block and post-block data at each time period, for both FEV1 and FVC, for the entire study population were made using paired t-tests. A repeated-measures analysis was used to compare raw change and percent change in FEV1 (sitting) over all times between groups. Results: The two cohorts had similar demographic data. There was 100% ipsilateral hemidiaphragmatic paresis in both groups at all post-block time periods. When the cohorts were compared there was no significant difference between the two in baseline pulmonary function (smallest p=0.7745). However, compared with the normal BMI group, the BMI >30kg/m² group was found to have a significantly greater percent decrease from baseline for measurements of sitting FEV1 and FVC at 15 and 30 minutes post-block (figure 1). [figure 1] These results were confirmed in the repeated-measures analysis for FEV1. No significant difference was seen between the groups for percent change in function for the supine position at any time point (smallest p=0.0797), or for any measurements in the PACU (smallest p=0.1194). Discussion: This prospective study provides evidence that the decrease in pulmonary function following ISB may be worse in obese patients, particularly during the 30 minutes after the procedure. However, significantly larger decreases from baseline were not seen for obese subjects in the PACU. This may support the conclusion that ISB in the ambulatory setting is equally safe for obese and nonobese patients. Recruitment for the study is ongoing, and more information is still needed. References: Urmey WF, McDonald M. Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics. Anesth Analg 1992;74:352-7. Disclosures: Nothing to disclose. A128 ULTRASOUND IDENTIFICATION OF ANTERIOR SCIATIC NERVE: A COMPARISON IN TRANSVERSE AND LONGITUDINAL AXIS E. Monzó, G. Ruiz, E. Abad, M. Hajro, F. Galindo Anaesthesiology, Fremap Hospital, Majadahonda-Madrid, Spain Introduction: The anterior approach of the sciatic nerve is used especially in patients in which the change to decubitus lateral or prone position, is not suitable or is not feasible. With ultrasounds and the usual position of the probe (cross section), the nerve is displayed as an hiperecoic oval structure. It is sometimes difficult to identify by the depth of the thigh muscles and it can be hidden by the lesser trochanter. The image of the nerve in the longitudinal section, improved considerably, appears as a long cable-like structure with a characteristic fascicular pattern, without the interposition of the lesser [1] trochanter Objective: Compare ultrasound identification of anterior sciatic nerve, in transverse and longitudinal axis. Material and method: Age mean Weight mean (Kg) Height mean (cm) BMI mean 20 Male 41.71 ±10.81 86.66 ±9.99 175.2 ±0.05 28.21 ±3.04 10 Female 50.11 ±8.43 70.55 ±11.36 160 ±0.05 27.65 ±4.62 [Table] In thirty patients (table) scheduled for lower limb orthopaedic interventions, we performed a combined sciatic and femoral block, choosing the anterior approach of the sciatic nerve. The patients were laid in supine with the lower limb in neutral position. Convex probe of low-frequency 2-5 MHz was placed in the anteromedial side of the upper thigh, 8-10 cm below the groin. We started the identification of the sciatic nerve in the transverse axis (Figure 1) [Figure 1] and subsequently in the longitudinal axis (Figure 2). [Figure 2] The punction was performed either "in plane" or "out plane", associating neurostimulation to 0.8mA. We injected 20 ml of mepivacaine 1.5%. Results: Of the 30 patients in which the probe was applied transversely to the thigh, in 22 (73,33%), we identified the oval hiperecoic image of the sciatic nerve. In the other 8 cases (33,33%),it was not possible to catalog any suggestive nerve image. With the probe applied sagittaly, it was achieved in all cases (100%) P=0,2; identifying an hyperechoic cable-like image running through the screen side by side, corresponding to the sciatic nerve. The block was successful in 29 cases (96,66%). Conclusion: The ultrasound identificationanterior sciatic nerve in the longitudinal axisis easier than in the transverse axis. The approximation and localization with the needle, as well as the spread of local anesthetic, are more evident in the longitudinal axis. [1] Tsui BC, Ozelsel TJ. Ultrasound-guided previous sciatic nerve block using a longitudinal approach: "expanding the view". Reg Anesth Pain Med. 2008 May-Jun; 33 (3): 275-6 doi: 10.1016/j.rapm.2007.11.008. A129 FIVE YEAR COMPARATIVE ANALYSIS OF PATIENTS PERCEPTION OF PAIN IN HOSPITALS IN UNITED STATES A. Nairizi, A. Gupta Anesthesiology, Drexel College of Medicine, Philadelphia, PA, USA Limited data are available regarding the quality of pain care in the hospitalized patient. In January 2012, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were released for review for health care providers and researchers. This survey includes a battery of questions for patients upon discharge from the hospital including pain-related questions and patient satisfaction that provide valuable data regarding pain care nationwide from October 2006 to March 2011. This study reviewed the results from the pain questions from this available data set and evaluate the performance of these hospitals in pain care in relationship to patient satisfaction. The data indicates that from 2006 to 2011, in average 68.5 % of patients gave a high global rating for their care, and that an additional 24.1% of patients felt that they usually received a high quality of care. When correlated to pain, we found that the relationship with overall hospital rating and always good pain control was moderately correlated (r > 0.55). In respect to the other HCAHPS components, we found that the patient and healthcare staff relationship is also moderately correlated with pain relief (r > 0.58). The current policies have not yet shown any significant improvement in patient pain satisfaction from 5 years ago. This study provides the evidence needed for hospitals to make pain care a priority in ultimately having patient satisfaction throughout the duration of their hospitalization. A130 EFFECT OF HUKO POINT ICE MASSAGE ON PAIN DEGREE DURING ARTERIOVENOUS FISTULA PUNCTURE IN HEMODIALYSIS PATIENTS F. Nasiri Ziba, F. Soltanpoor, N. Mohammadi Medical Surgical Department, Tehran University of Medical Sciences, Medical School, Tehran, Iran Background: Pain is described as the fifth vital sign and inadequate pain management is linked to numerous immediate and long - term negative outcomes. Vein puncture is one of the most painful medical procedures and one of the most frequently performed ones non-pharmacological interventions can be implemented independently by nurses. The purpose of this study was to evaluate the effect of ice huko point massage on pain during arterio-venous fistula puncture. Intervention: In randomize control trial study, ninety (90) patients in hemodialysis wards were randomly assigned to either the huko point ice stimulation(n=30) and two control group (n=30) who were undergoing hemodialysis by using AVF. We were randomly assigned to experimental and control groups using a randomization table. The experimental group received ice massage on hoku point, the first control group received massaged on wrist and second control group received massage on huko point. Outcome: At first day without intervention ,arterio-venous fistula puncture pain was measured by visual analogue scale. on second day after 10 minutes intervention in 3 groups pain degree was measured. There were significant statistical difference in 3 groups after interventions( p=./001) Conclusion: These findings showed that huko point ice massage was effective and safe for decreasing on pain degree during arterio-venous fistula puncture in hemodialysis patients. A131 PULMONARY HYPERTENSION IN A PARTURIENT MANAGED WITH AN INTERMITTENT SPINAL INFUSION FOR CESAREAN SECTION D. Nguyen, C. Martinello, J. Kwan, A. Singal, A. Van, E. Hurwitz Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA Pulmonary hypertension during pregnancy is a relatively rare condition that can affect many patients differently during the parturient course. In our institution, the Anesthesiology service was consulted in advance on a term pregnant patient with severe pulmonary hypertension for cesarean section. Before performing any anesthetic interventions, we performed a literature review to determine the epidemiology and the most optimal treatment plan for pulmonary hypertension during pregnancy. Our patient´s treatment plan for the cesarean section was with an epidural catheter for surgical anesthesia, but an inadvertent dural puncture by another Anesthesiologist occurred during epidural placement. Subsequently, the patient was managed with an intermittent intrathecal infusion of hyperbaric 0.75% bupivacaine and preservative-free morphine without any complications. In our literature review, the terms "pulmonary hypertension" alone and with the keywords “pregnancy”, “pregnant”, and “parturient” were used as the search subject. The following medical search databases were utilized: Pubmed, Cochrane Library, United States National Library of Medicine, MDConsult, Medscape, Google and Google Scholar, Merck Manual, Web Directory of Medical Education, and UpToDate. After examination of the 57 collected papers and reports, 44 publications were found that the abstract´s authors felt were of clinical relevance towards our case patient. Pulmonary hypertension (in parturients and non-parturients) has been classified by the Venice Clinical Classification system updated by the Dana Point Classification system into five major clinical categories of pulmonary hypertension as determined by its etiology. Based upon the literature review, the parturient patient with pulmonary hypertension often becomes symptomatic during the end of the second trimester or during the beginning of the third trimester. However, the most most critical time for these patients is immediately postpartum and up to one month after delivery. Due to the relatively rare number of cases of diagnosed pulmonary hypertension during pregnancy, much of the literature is based upon case reports, anecdotal data, and retrospective reviews. Randomized clinical trials are not available to formulate an absolute recommended treatment algorithm. Pharmacologic treatment options include prostaglandins, inotropic agents including phosphodiesterase-3 inhibitors and dobutamine, vasopressors such as norepinephrine or phenylephrine, sildenafil, and inhaled nitric oxide. Specific anesthetic considerations include attention to arterial oxygen saturation, cardiac rhythm, and blood pressure. A central venous catheter and arterial catheter for invasive blood pressure monitoring are routinely recommended. Pulmonary artery catheters are generally considered on a case-by-case scenario, and the risks of the catheter and placement must be weighed against the diagnostic benefits. When vaginal delivery is chosen, low dose epidural anesthesia should be placed early in labor as it often decreases the adverse hemodynamic effects of labor. Epidural anesthesia with slow titration to the desired effect seems to be the safer technique in case a cesarean delivery is indicated, although our patient was treated with an intrathecal infusion without any adverse effects. Pulmonary hypertension during pregnancy is a rare condition, and treatment often needs to be individualized for each patient. Further research on parturients with pulmonary hypertension will likely be beneficial in determining optimal treatment plans for this patient population. A132 CONVERSION OF CHRONIC PAIN PATIENTS FROM HIGH DOSE FULL-OPIATE AGONISTS TO SUBLINGUAL BUPRENORPHINE 1 2 1 1 J. Daitch , D. Daitch , D. Novinson , C. Mitnick , J. Pergolizzi 1 3 2 Advanced Pain Management Specialists, Fort Myers, FL, Thomas Jefferson University, 3 Philadelphia, PA, Johns Hopkins University, Baltimore, MD, USA Introduction: Buprenorphine SL is unique among the opiate class of analgesics; this compound has a high affinity for the µ-receptor, yet only partially activates it. Thus, buprenorphine SL can provide analgesia while minimizing opiate side effects. Sublingual buprenorphine (buprenorphine SL) is a preparation that has been used to treat opiate dependence. Nevertheless, the Drug Enforcement Administration (DEA) has acknowledged the legality of an off-label to use treat pain with the sublingual buprenorphine preparation (1). Many patients on high doses of opiate medication develop opiate-induced hyperalgesia (2), which may limit efficacy. The purpose of this study is to determine the effectiveness of converting patients from high doses of full agonist opiate medication to sublingual buprenorphine, as well as to identify patient groups that are most likely to benefit from this therapy. Materials and methods: Retrospective data from clinical records was taken from 35 de-identified chronic pain patients (22 male and 13 female, age 24-66) who had previously been treated with highdose opiate-agonist drugs and were converted to buprenorphine SL in tablet form during the study. High dose opiates were defined as over 200 mg morphine equivalent per day. Patients ranged from morphine equivalents of 200mg to 1370mg. Data collected from patient profiles included age, sex, diagnosis, medication history, pre-induction opioid intake, and pre-induction Clinical Opiate Withdrawal Score (COWS). Numerical pain levels and Quality of Life scores were recorded before and after conversion to buprenorphine SL. Results: [Pre-, Post-Conversion Scores by Initial Pain] After continuation of buprenorphine SL therapy for more than two months, the mean pain scores in all groups decreased by 3.7 points (p< 0.001) which was more than a 50% decrease in numerical pain score from 7.2 to 3.5. [Pre-, Post-Conversion Scores by Morphine Equivs.] The mean daily pre-induction morphine equivalent dose of opiate was 550 mg. Patients with morphine equivalents of 200-400mg decreased the most in pain score with a 62% decrease in pain. Patients taking over 400mg morphine equivalents decreased 43% in pain scores. This may be related to a decrease in opioid-induced hyperalgesia. In addition, all patients who were on high dose opiate medication, regardless of their initial pain score, responded with improved analgesia after conversion to buprenorphine. The average dose of buprenorphine SL was 28.11mg +/- 5.94. Patient Quality of Life (QOL) scale was not significantly affected by buprenorphine SL therapy (p=0.087). Discussion: Patients converting from high dose full-opiate agonists from 200mg to 1370 mg of morphine equivalents who continued buprenorphine SL therapy for more than 60 days reported a significant decrease in pain of >50% from 7.2 to 3.5 (3.7 points). This cannot be completely explained as elimination of opiate-induced hyperalgesia, since even patients at low levels of pain (1-7) on high doses of opiates also experienced significant decreases in pain. References: 1. Heit H, Covington E, Good P. Dear DEA. Pain Med 2004;5:303-308. 2. Angst M, Clark J. Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570-587. Funding: None A133 ULTRASOUND-GUIDED PARAVERTEBRAL CATHETERS VERSUS INCISIONAL LOCAL ANESETHETIC INFUSION AND PATIENT CONTROLLED ANALGESIA FOR POST-OPERATIVE PAIN CONTROL IN SINGLE LUNG TRANSPLANT PATIENTS: A RETROSPECTIVE COHORT 1 1 2 K. Ohden , R. Kelly , J. D'Cunha , J. Hutchins 1 1 2 University of Minnesota, Minneapolis, MN, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Introduction: Recent studies have shown that paravertebral catheters provide superior pain control over incisional local anesthetic pumps with narcotic PCAs and possibly associated with less adverse 1,2 events. Prior to November 2011 at the University of Minnesota, single lung transplantation patients' post-operative incisional pain was treated with an incisional local anesthetic infusion with a narcotic PCA. However, after November 2011, paravertebral catheters were the treatment of choice for lung transplant patients´ postoperative pain. We sought to determine whether a paravertebral catheter and opioid PCA provided improved pain control with decreased narcotic use in patients undergoing lung transplantation when compared to those who had an incisional local anesthetic infusion with opioid PCA. Methods: This was a retrospective cohort chart review of 16 patients, 8 patients who had a paravertebral catheter and 8 patients who had an incisional local anesthetic pump and opioid PCA for a single lung transplant from January 2011 to September 2012. Narcotics were normalized to fentanyl equivalents and pain scores were obtained by the bedside nurse, anesthesia resident, or acute pain nurse clinician. Results: There was no significant difference in baseline characteristics between the two groups. Those with paravertebral catheter had significantly less pain at rest when compared to local anesthetic incisional pumps on catheter day 1, 3, and 5 with a trend toward decreased pain scores on 2, 4, 6, and 7. Those with a paravertebral catheter had significantly less pain scores with movement compared to local anesthetic infusion on catheter day 2, 4, and 6 with trend toward decreased pain scores on days 1, 3, 5, and 7. There was a significantly decreased amount of narcotic used in those patients with paravertebral catheter on catheter day 3 and 4 with trend towards decreased narcotics on days 1, 2, 5, 6, and 7. The total narcotics used was 1339 mcg +/- 134 mcg of Fentanyl in those with paravertebral vs 2525 mcg +/- 638 mcg in those with an incisional local anesthetic infusion p = 0.0904. There were no significant differences in complications or side effects between the two groups. Discussion: This study suggests that paravertebral catheter infusion offers improved pain control and decreased narcotic use when compared to incisional local anesthetic infusion. References: 1. Kotze, A., A. Scally, and S. Howell. "Efficacy and Safety of Different Techniques of Paravertebral Block for Analgesia after Thoracotomy: A Systematic Review and Metaregression." British Journal of Anaesthesia 103.5 (2009): 626-36 2. Marret E, Vigneau A, Salengro A, Noirot A, Bonnet F. Effectiveness of analgesic techniques after breast surgery: A meta-analysis. Ann Fr Anesth Reanim 2006; 25:947-54. Disclosure: J. Hutchins is on the speaker´s bureau for I-Flow. A134 ASSESSING THE NEED FOR POSTOPERATIVE SCIATIC NERVE BLOCK FOR PAIN RELIEF AFTER NON-HAMSTRING ACL RECONSTRUCTION K.M. Hibbard, S.L. Orebaugh, B.A. Williams, M.L. Kentor Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA Introduction: Postoperative analgesia for patients undergoing ACL reconstruction commonly involves a femoral nerve block (1). However, sciatic block is also occasionally required as well when dermatomes, myotomes, and/or osteotomes of this nerve may be affected by incision or drilling (2). We evaluated adequacy of postoperative pain relief in patients undergoing ACL reconstruction with preoperative femoral block and general anesthesia with "multimodal" analgesia. Specifically, we determined the frequency sciatic nerve block was required as a supplemental block in PACU for pain relief. Methods: Forty-Six ASA 1 and 2 patients receiving allograft or patellar tendon autograft ACL were enrolled. Each received multimodal analgesia with preoperative femoral nerve block, acetaminophen 1000 mg PO, ketamine 25-50 mg IV, and hydromorphone 1-2mg IV. Pain scores were recorded in PACU on arrival and at ten minute intervals. Patients whose pain scores remained greater than or equal to 5/10 received a postoperative sciatic block. Results: Patient demographics are reported in Table 1. No Post-Op Sciatic Post-Op Sciatic 37 9 28.05, (9.81) 27, (9.31) 78.38 77.78 27.61, (5.34) 25.8, (3.88) Cadaver Allograft, n (%) 8, (21.66) 2, (22.22) Patella Tendon Autograft, n (%) 29, (78.34) 7, (77.78) n Age, yr, (SD) Male, % BMI, (SD) [Table 1: Patient Demographics] Nine out of 46 (19.56%, CI 10 - 33%) patients required postoperative sciatic block based on the listed criteria. Patients who received a sciatic block had a mean pain score of 6.7/10 after 10 minutes in the PACU, while those who did not had a mean pain score of 4.4/10 (p=.0038). Patients that required a postoperative sciatic block also received a higher dose of intraoperative hydromorphone 0.8 vs. 0.38 mg (p=.017). After sciatic block, pain scores decreased from a mean of 6.6 to 2.6. No Post-Op Sciatic Post-Op Sciatic 0.97, (1.21) 1.67, (1.66) 36.48, (16.24) 38.89, (13.18) Intra-Op Dihydromorphone, mg, (SD) 0.38, (0.41) 0.27, (0.48) Pain Score, PACU Arrival, (SD) 3.39, (3.74) 5.72, (3.60) Pain Score, 10 mins in PACU, (SD) 1.08, (3.25) 6.78, (2.17) PACU; Dihydromorphone, mg, (SD) 0.7, (0.62) 0.77, (0.36) Pre-Op Pain Score, (SD) Intra-Op Ketamine, mg, (SD) [Table 2: Patient Data] Conclusion: Femoral nerve block plus multimodal analgesia provided adequate pain relief in 37 out of 46 of patients receiving cadaver allograft or patellar tendon autograft ACL reconstruction. References: 1. Williams BA, Kentor ML, Vogt MT, Irrgang JJ, Bottegal MT, West RV, Harner CD, Fu FH, Williams JP. Reduction of Verbal Pain Scores after Anterior Cruciate Ligament Reconstruction with 2-Day Continuous Femoral Nerve Block. Anes 2006; 104:315-27. 2. Dauri M, Fabbi E, Mariani P, Faria S, Carpenedo R, Sidiropoulou T, Coniglione F, Silvi M, Sabato A. Continuous femoral nerve block provides superior analgesia compared with continuous intraarticular and wound infusion after anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2009; 34:95-99. A135 ASSESSMENT OF A CHECKLIST-BASED EDUCATIONAL TOOL FOR ULTRASOUND-GUIDED INTERSCALENE PERIPHERAL NERVE BLOCKADE J. Resti, S. Orebaugh, Division of Acute Interventional Pain and Regional Anesthesia Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Introduction: Checklists have become an indispensable tool in ensuring patient safety in modern medicine (1,2). In regional anesthesia, checklists have been demonstrated to improve management decisions in simulated complications (3). We evaluated the adherence of residents to a previously validated block checklist in clinical care during a regional anesthesia/ambulatory rotation, and secondarily the contribution that this checklist made to attending evaluations of resident performance. Materials and methods: A 34-point, task-specific checklist, adapted from other sources and previously validated (4), was tailored for single-shot interscalene peripheral nerve block (Figure 1). Over a 6 month period, senior and junior residents underwent a partial-task trainer simulation on the first day of the regional anesthesia rotation with this checklist. During this exercise, residents completed each task on the checklist, while providing an ultrasound-guided “block” to a gel model adjacent to the neck of a mannequin. During the rotation, residents had access to the checklist, but were not specifically directed to it. Later in the rotation, residents underwent evaluation for fidelity to the checklist during an actual interscalene block.. Residents were also asked demographic questions at this time (Figure 2). The mean number of correct checklist items were compared for senior and junior residents utilizing a simple t-test. [Figure 1. Task-specific Checklist] [Figure 2. Questionnaire] Results: Overall, 7 junior (PGY-2/3) and 5 senior (PGY-4) residents participated. The mean overall number of items correct on the checklist was 32.5. This did not vary between the junior and senior residents (Table 1). The most commonly missed items were tabulated (Table 2). Junior Residents (n=7) Senior Residents (n=5) P value Comfort Level of PNB 2.0 2.5 0.20 Number of USG PNBs 62.3 125.2 0.06 Number of USG ISBs 31.8 56.3 0.12 Number of Items Completed Correctly 32.2 33.1 0.46 [Table 1] Missed Item Frequency Turns on doppler function to scan for vessels at injection site 5 Warns patient about discomfort on injection 5 Warns patient about nerve stimulation/motor twitch 3 Prepares probe in sterile fashion 1 Checks that nerve stimulator is attached 1 Checks that block needle is appropriate and primed 1 [Table 2] Discussion: Residents exposed to a partial-task trainer to practice ultrasound-guided block while enacting a checklist, displayed high fidelity to the checklist during actual block conduct later in the rotation. References: 1. WHO surgical safety checklist. WorldAllianceforPatientSafety, http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html 2008. 2. Pronovost, P et al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEnglJMed. 2006;355:2725-32. 3. Neal JM, et al. ASRA checklist improved trainee performance during a simulated episode of local anesthetic systemic toxicity. RegAnesthPainMed. 2012;37(1):8-18 4. Naik VN et al. An assessment tool for brachial-plexus regional anesthesia performance: establishing construct validity and reliability. RegAnesthPainMed. 2007;32(1):41-5. FUNDING: None. A136 USE OF ULTRASOUND GUIDANCE FOR PERIPHERAL NERVE BLOCKADE AT A LARGE ACADEMIC HEALTH CARE SYSTEM OVER A 6-YEAR PERIOD S. Orebaugh, E. Conrad III, D. Taormina, D. Webb, J. Chelly 1 Department of Anesthesiology, Division of Acute Interventional Pain and Regional Anesthesia, 2 3 University of Pittsburgh, Department of Anesthesiology, Division of Acute Perioperative Pain and 4 Regional Anesthesia, University of Pittsburgh, Division of Acute Interventional Pain and Regional Anesthesia, University of Pittsburgh, Pittsburgh, PA, USA Introduction: Although the benefits associated with the use of ultrasound (US) to perform peripheral nerve blocks remain the object of passionate debates, this approach has gained recognition. This study was conducted to assess how the use of ultrasound evolved in the Division of Acute Interventional Perioperative Pain and Regional Anesthesia (DAIPPRA) over a period of 6 years. Method: DAIPPRA of the Department of Anesthesiology at the University of Pittsburgh performs peripheral nerve blocks as part of acute postoperative pain management at 13 different UPMC hospitals, including 4 ambulatory centers and 2 trauma hospitals, a pediatric hospital, University and Community Hospitals. Using our IRB approved registry, the overall number of blocks performed at each center was established over a six year period, including the % of blocks performed with US, to demonstrate the evolving use of ultrasound guidance. Results: Our data indicate that a 10 fold increase in the use of US occurred between 2007 and 2010. This was the result of an increase in the use of ultrasound at each site, especially for lower extremity and paravertebral blocks. In addition, US was utilized more frequently at ambulatory centers, where mostly single and superficial blocks are performed, vs. inpatient facilities (90% vs. 48%). Table 1 presents the total number of blocks (blocks) and the relative frequency of the use of ultrasound (%), for the Division (Overall) and per each reported site in 2007, 2010, and 2012. Discussion: Ultrasound guided techniques have impacted the performance of peripheral nerve blockade in many ways in the past decade (1). US allows visualization of the target nerves, and facilitates the performance of certain blocks including supraclavicular, and transversus abdominis plane blocks (2,3). Although it is clear that US guidance techniques are increasingly used in our institution, the use of neurostimulation alone or in combination with US continues to be a valuable alternative, especially for deep lower extremity blocks. Funding: No specific funding was utlized for this study. References: 1. Abrahams MS. Br J Anaesth 2009;102:408. 2. McCartney CJ. Reg Anesth Pain Med 2010;35:S10. 3. Abrahams MS. Reg Anesth Pain Med 2010;35:S36. Table 1. Total number of blocks (blocks) and the relative frequency of the use of ultrasound, overall and per hospital in 2007, 2010, and 2012. [Table 1] A137 PERCEPTION VERSUS REALITY: THE INCREASING AMERICAN HABITUS AND ITS IMPACT ON PERI-OPERATIVE MANAGEMENT A.M. Oviedo, S.M. Moeschler, C.M. Duncan, H.M. Smith, S.L. Kopp Anesthesiology, Mayo Clinic, Rochester, MN, USA Introduction: Obesity, defined as a body mass index (BMI) greater than 30 kg /m2, has increased 1, 2 significantly over the past twenty years in the United States . As a result the rate of total joint 3 replacements has steadily increased over time . For example, total knee arthroplasties (TKAs) are being performed in younger individuals and these patients have more comorbidities including diabetes 4 mellitus, obesity, hypercholesterolemia, hypertension, and pulmonary disease . The primary aim of this study was to determine the demographic trends of patients undergoing primary TKA during three different time periods: 1989, 1999 and 2009 at our institution and to determine if it mirrors the changing demographics within the United States. Methods: All adult patients that have undergone unilateral primary TKA during the calendar years of 1989, 1999 and 2009 were identified via the Mayo Clinic Total Joint Registry database. Two hundred patients were randomly selected for each time period. A retrospective chart review of patient demographics, comorbidities, perioperative practice and postoperative outcomes was performed. We also studied the perception of experienced anesthesia providers regarding changes, or lack thereof, in patient demographics and perioperative care via a web-based survey. Results: During the three study periods a total of 590 patients were included for the analysis. Two hundred patients from 1989; one hundred and ninety-three patients from 1999 and one hundred and ninety-seven patients from 2009. A statistically significant increase in BMI was observed overtime in patients undergoing primary TKA (average BMI: 29.01 in 1989; 31.32 in 1999 and 32.28 in 2009 (p < 0.001)). There was an increase in the number of patients with recognized preexisting comorbidities such as hypertension, diabetes and obstructive sleep apnea. Despite the increase in patient comorbidities, the number of postoperative complications decreased and postoperative disposition (general medicine ward vs. ICU) did not change significantly. The administration of exclusively general anesthesia declined. On the other hand, combined general and regional anesthesia increased significantly. Our survey received 76 % response rate. The majority of anesthesia providers perceive that BMI has increased (average time in practice: 11 years) simultaneously with the number of comorbidities. This trend in body habitus and rise in comorbidities leads the majority of the practitioners to modify their perioperative anesthesia care. Discussion: The number of obese patients with comorbidities presenting for TKA at our institution is growing. Despite the fact that we are taking care of more complicated patients, a reduction in postoperative complications was detected. This could be explained by anesthesiology practice modifications including the increased implementation of regional anesthesia protocols, utilization of non-narcotic analgesics and short acting medications. References: 1. CDC. U.S. Obesity trends. November 24, 2009. 2. CDC. Available from: http://www.cdc.gov/nchs/nhanes/about_nhanes.htm 3. Kurtz, S., et al., Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am, 2005. 87(7): p. 1487-97. 4. Memtsoudis, S.G., et al., Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J Arthroplasty, 2009. 24(4): p. 518-27. A138 A SURVEY OF KNOWLEDGE RELATING TO THE CAUSES, SIGNS AND TREATMENT OF LOCAL ANAESTHETIC TOXICITY (LAST) S. Patel, S. West, D. Kamming 1 2 University College Hospital, Anaesthetics, UCLH, London, UK Introduction: Local anaesthetics are commonly used within the operating theatre suite to provide intra and post operative analgesia. This may be via a number of routes including epidural, peripheral nerve block and subcutaneous infiltration. 1 Local anaesthetic toxicity (LAST) is rare, with an incidence of 0.08 per 1000 quoted by Sites , but potentially fatal. Avoidance of LAST requires knowledge of safe maximum doses of drugs, recognition and of appropriate treatment. The use of lipid emulsion to treat LAST has been understood for many 3 years, and more recently been incorporated into several guidelines including those from the AAGBI 2 in the U.K. and ASRA in North America . Despite the increased availability of lipid emulsion in the U.K over the last ten years, knowledge of its use is often variable. We sought to assess the level of understanding of local anaesthetic doses and the effective management of LAST within a busy University Hospital anaesthetic department. Methods: A confidential questionnaire was distributed amongst both trainee anaesthetists and consultant anaesthetists over a one-week period within the anaesthetic department. Questions assessed knowledge of maximum local anaesthetic doses, signs and symptoms of local anaesthetic toxicity, the awareness of guidelines used to treat LAST and the dosages and availability of Intralipid (lipid emulsion therapy). Results: 18 anaesthetic trainees and 20 anaesthetic consultants participated in the questionnaire. 82% correctly identified the correct maximum safe dose of both lignocaine and bupivacaine , although when asked only 61% were able to translate this to an appropriate volume of 2% lignocaine. 100% of anaesthetists correctly identified both the neurological and cardiac signs of LA toxicity. 100% were aware of the availability of guidelines and the use of Intralipid to treat LAST. Only 12%, however, were able to state the loading , maintenance and maximum dose of Intralipid and only 40% correctly identified where it was kept. Conclusion: Those using local anaesthetic should know the maximum safe dosages to avoid LAST and how to manage LAST accordingly. This group had a good understanding of maximum safe doses of local anaesthetics, however failings were demonstrated when asked to translate this into a clinical volume for use. The ability to recognise LAST was well demonstrated by the knowledge of signs and symptoms relating to LAST. The awareness of guidelines and the use of Intralipid to treat LAST was evident but there was still a lack of knowledge on how to use Intralipid appropriately and where to find it. Further to these results we propose an intervention of training in the use of Intralipid and a subsequent re-audit of knowledge. References: 1. Sites, Brian Daniel et al. Incidence of Local Anesthetic Systemic Toxicity and Postoperative Neurologic Symptoms Associated With 12,668 Ultrasound-Guided Nerve Blocks: An Analysis From a Prospective Clinical Registry. RAPM 2012; 37(5) 478-482 2. Management of Severe Local Anaesthetic Toxicity 2 , Association of Great Britain and Ireland, published December 2010. 3. Neal JM et al American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: RAPM 2012 37(1) A139 PREOPERATIVE THORACIC PARAVERTEBRAL BLOCKS ARE ASSOCIATED WITH LESS INTRAOPERATIVE LONG ACTING IV OPIOID USE IN PATIENTS UNDERGOING BREAST SURGERY R. Pathak, S. Lien, S. Coopey, M. Specht, K. Fleischmann 1 2 Department of Anesthesia, Critical Care, and Pain Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Introduction: Preoperative thoracic paravertebral blocks (TPVB) in patients undergoing breast surgery have been shown to reduce postoperative pain, lower opioid requirements on the first postoperative day, decrease postoperative nausea and vomiting, and decrease length of stay. However, no prior studies have shown a significant decrease in the amount of long acting IV opioids used intraoperatively. We report our institutional experience with the use of TPVB in patients undergoing unilateral or bilateral mastectomy with immediate reconstruction (tissue expander or implant placement). Materials and methods: With Institutional Review Board approval, 160 patients were retrospectively identified who underwent preoperative TPVB prior to mastectomy with immediate reconstruction at a single institution in 2012. This group was compared to a similar group of 126 patients who underwent mastectomy with immediate reconstruction without the use of TPVB in 2008. The doses of IV opioids used intraoperatively were compared between the two groups. Results: The total dose of long acting IV opioids (hydromorphone) given intraoperatively to the group that received TPVB (0.97mg, 95% CI: 0.89-1.07) was significantly less than that given to the group that did not receive TPVB (1.71mg, 95% CI: 1.56-1.85) (p< 0.0001). The amount of short acting IV opioids (fentanyl) was not significantly different between the two groups (p=0.11). Discussion: We conclude that preoperative TPVB significantly decreased the amount of long acting IV opioid used intraoperatively. This decrease in opioid requirement may contribute to the lower rate of PONV, faster transition time to oral opioids, and shorter length of stay seen in patients who undergo preoperative TPVB, as previously shown by our regional group. [Mean Amount of Hydromorphone (mg) Administered ] TPVB Group (n=160) Non- block Group (n=126) p-value Hydromorphone(mg) 0.97 (95% CI: 0.891.07) 1.71 (95% CI: 1.561.85) P < 0.0001 Fentanyl (mcg) 189.7 (95% CI: 173.25206.1) 169.02 (95% CI: 149.55P = 0.11 188.48) [Comparison of TPVB Group to Non-Block Group] References: Use of Preoperative Paravertebral Block Decreases Length of Stay in Patients Undergoing Mastectomy Plus Immediate Reconstruction. Coopey SB, Specht MC, Warren L, Smith BL, Winograd JM, Fleischmann K.Ann Surg Oncol. 2012 Oct 14. General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis. Tahiri Y, Tran de QH, Bouteaud J, Xu L, Lalonde D, Luc M, Nikolis A. J Plast Reconstr Aesthet Surg. 2011 Oct;64(10):1261-9. Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery. Boughey JC, Goravanchi F, Parris RN, Kee SS, Kowalski AM, Frenzel JC, Bedrosian I, MericBernstam F, Hunt KK, Ames FC, Kuerer HM, Lucci A. Am J Surg. 2009 Nov;198(5):720-5 Thoracic paravertebral block for breast surgery. Klein SM, Bergh A, Steele SM, Georgiade GS, Greengrass RA. Anesth Analg. 2000 Jun;90(6):1402-5. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Acta Anaesthesiol Scand. 1999 Aug;43(7):770-4. Funding/disclosures: none A140 THE SPREAD OF LOCAL ANESTHETIC SOLUTION WITH BLOCKADE OF THE SCIATIC NERVE WITH THE USE OF ULTRASOUND GUIDANCE V. Piacherski, A. Marachkou, Z. Kokhan, A. Brukhnov Health Care Institution «Mogilev Regional Hospital», Mogilev, Belarus Aim of the work: To study the features of local anesthetic solution spreading during sciatic nerve block, in dependence of the injected anesthetic solution volume. Material and methods: We have analyzed the results of 79 cases of sciatic nerve block in combination with femoral nerve block, in 79 patients in period 6 Jun 2009 - 1 Jul 2010, performed in Mogilev Regional Hospital. The age of patients was 42.3±13.7 years. Sexes distribution was: 45 male and 65 female patients. Sampling was carried out by a solid. For providing the intraoperational anesthesia, all blocks were performed by lidocaine solution of different concentrations, of the volume 25; 20; 15; 12.5; 10; 7.5; 6.5; 5; 4.5 ml, with addition of adrenalin (1:200 000). For verifying the position of the needle and sciatic nerve, ultrasonic visualization in combination with peripheral nerves electric stimulator were applied. In this procedure, after obtaining the sonographic signs of sciatic nerve at ultrasonic apparatus screen, the injection needle was approached to the nerve under ultrasonic control, till the appearance of muscle contractions of the appropriate muscle group. The frequency of nerve stimulation was 1-2 Hz; the electric stimulator generated impulses of direct current with the strength 0.1-1.0 mA, voltage 1-10 V and impulse length 0.1 msec. After the block performing, the second anesthesiologist, who did not know about the amount of injected local anesthetic solution, independently measured cross-section area of sciatic nerve (S1) and total cross-section area of sciatic nerve together with the ring of local anesthetic around the nerve (S2). These measurements were done by means of ultrasonic apparatus software. The cross-section area of the ring (S), corresponding to local anesthetic, was defined as the difference between S2 and S1. Taking into account such character of spreading, to determine the length of anesthetic passing along the nerve, we applied the formula QUOTE , where L - the length of local anesthetic spreading 2 (cm), V - the volume of injected local anesthetic (ml), S - cross-section area of local anesthetic (cm ). Results: The anesthetic agent solution spreads along sciatic nerve in proximal and distal direction, forming a kind of cylinder. The minimum volume of the local anesthetic, which covers sciatic nerve in the whole, is 5 ml. Minimum volume of local anesthetic solution, which wraps totally around sciatic nerve in adult patients, is 5 ml. The full spreading of the local anesthetic around sciatic nerve was not observed, if 4.5 ml of the solution were used. V, ml L, sm S, sm2 4,5 (n=5) 8,49(6,92;10,97) 0,53(0,41;0,65) 5(n=9) 11,36(10,41;13,51) 0,44(0,37;0,48) 6,5(n=5) 10,83(10,79;1085) 0,61(0,60;0,62) 7,5(n=5) 13,30(13,20;13,50) 0,69(0,68;0,70) 10(n=12) 13,52(12,73;15,03) 0,74(0,66;0,78) 12,5(n=6) 12,82(11,90;14,08) 0,78(0,71;0,84) 15(n=12) 18,43(14,85;20,98) 0,81(0,71;1,01) 20(n=9) 20,40(18,18;20,23) 0,98(0,96;1,10) 25(n=16) 21,20(20,16;23,29) 1,18(1,07;1,24) [Table 1] A141 DESCRIPTION OF THE SONOANATOMY OF THE SUPRASCAPULAR AND AXILLARY NERVES D. Price, N. Kershaw, L. Zhou North Shore Hospital, Auckland, New Zealand Introduction: Combined suprascapular and axillary nerve blockade (CSANB) has been shown to provide comparable analgesia to interscalene block following arthroscopic shoulder surgery, with significantly less side effects (1). CSANB was originally described using anatomical landmarks and a nerve stimulator (2). However, ultrasound (US) guidance has recently become the preferred technique for peripheral nerve blockade. The aim of this descriptive study is to determine how effectively the suprascapular nerve (SN )and the axillary nerve (AN), which are both small and deep to large muscles, and adjacent anatomical structures can be imaged with US. Method: US imaging was performed bilaterally on 50 seated volunteers. Images were generated at 3 separate points along the course of each nerve, in both short axis (SAX) and long axis (LAX), resulting in a total of 1200 separate US images. Each structure was assigned an image rating score of 0 (not visible), 1 (poor), 2 (reasonable) or 3 (excellent). Results: The estmated nerve depth for AN was greatest in the quadriteral space, and for SN, the greater scapular notch. AN was shallowest on the lateral surface of humerus, and SN, the suprascapular notch. Bone was the most reliably imaged structure in all views, while both arteries was seen more reliably than either nerve (Table 1). The best image of the SN and artery is the in the supraspinous fossa, in LAX on the right and SAX on the left. The best image of the AN and circumflex artery is the posterior surface of the humerus in LAX on both sides. Conclusion: Images of anatomical structures relevant to the performance of US-guided CSANB were able to be located, and their image quality rated, in this purely descriptive study. References: 1. Price D, Abeysekera A, Chaddock M. A randomised comparison of combined suprascapular and axillary (circumflex) nerve block with interscalene block for postoperative analgesia following arthroscopic shoulder surgery. Anaesth Intensive Care 2012. 40,1 183-184 2. Price DJ. The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesthesia Intensive Care 2007;35:575-581 Funding: There are no funding disclosures to make for this study. Personal conflicts of interest disclosure: There are no conflict of interest disclosures to make for this study. A142 ARTHROPLASTY CARE REDESIGN: IMPACT OF SPINAL DOSING ON POST ANESTHESIA RECOVERY UNIT LENGTH OF STAY AFTER TOTAL KNEE ARTHROPLASTY S. Pritzlaff, E.A. Jacob, K. McCarty, M. Rozanski, R. Dorman, O.V. Evgenov, K. Fleischmann, A. Freiberg, M. Gargarian, W. Levine, J. Lewis, V. Modest, P. Stefanovich, S. Vassallo, J. Wang, L. Warren, L. Wollman-Kliman, J. Rathmell, R. Peloquin, MGH Arthroplasty Care Redesign Team 1 2 3 Anesthesia, Critical Care, and Pain Medicine, Physical Therapy Services, Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA Introduction: The MGH Arthroplasty Care Redesign Team was charged with evaluating our arthroplasty care with the aim of reducing cost while maintaining or improving quality. An initially identified limitation to early ambulation and thus overall length of hospitalization was extended length of stay in the PACU (PACU LOS), particularly among patients receiving spinal anesthesia (SA) for 1 Total Knee Arthroplasty (TKA). This led to a systematic examination of TKA SA dosing and subsequent efforts to reduce those doses. Here, we retrospectively analyzed the influence of SA bupivacaine doses on PACU LOS after TKA in comparison with use of general anesthesia (GA). Methods: Using our perioperative electronic health record, we retrospectively reviewed all adult patients who underwent TKA at MGH from January 2010 - September 2012. Beginning in January 2012, anesthesia practitioners were encouraged to reduce isobaric bupivacaine doses used for TKA. TKA performed during January 2010 - September 2011 were assigned to Period 1; TKA performed during January - September 2012 were assigned to Period 2. The primary endpoint was PACU LOS, defined as surgical close to medically ready to leave the PACU. All data are shown as mean ± standard deviation and were analyzed using two-tailed t-tests with significance set at p< 0.05. Results: 955 TKA were performed during Period 1: 351 under GA and 604 under SA. 464 TKA were performed during Period 2: 210 under GA and 254 under SA. The SA dose of 0.5% bupivacaine decreased from 17.3±2 mg in Period 1 to 13.9±2mg in Period 2 (p< 0.001). [Table 1] PACU LOS in those receiving SA decreased from 265±109min during Period 1 to 217±91min during Period 2 (p< 0.001). PACU LOS decreased in those receiving GA from 211±94min during Period 1 to 199±93min during Period 2, though not significantly (p = 0.08). For all TKA patients, PACU LOS decreased from 245±107min during Period 1 to 209±92min during Period 2 (p< 0.001). [Figure 1] The overall reduction in PACU LOS during Period 2 was 16,704 minutes. Discussion: Extended PACU LOS delays physical therapy and mobilization following TKA. Examination of our anesthetic outcomes led to a significant reduction in SA doses and an associated reduction in PACU LOS, suggesting enormous implications for PACU efficiency and cost containment. Further study is needed to establish optimal SA dosing that assures sufficient anesthesia duration while minimizing recovery time. References: 1. McCarty et al., “Impact of General versus Spinal Anesthesia on Post-Anesthesia Care Unit Recovery Time Following Total Hip and Knee” ASA Conference Abstract October 2012. Funding: MGH CQS - Clinical Innovation Award COIs: none A143 PAIN, ANXIETY AND DEPRESSION FOLLOWING TRAUMATIC MUSCULOSKELETAL INJURY B.N. Rosenbloom, L. Bosco, L. Haslam, H. Kreder, J. Katz, C.J. McCartney 1 2 3 Institute of Medical Science, University of Toronto, Lawrence S. Bloomberg Faculty of Nursing, 4 5 University of Toronto, Orthopedics, Sunnybrook Health Sciences Centre, Department of Psychology, 6 York University, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Traumatic injury is the fourth leading cause of death. The most common injuries from trauma are orthopedic, which often require surgical interventions. Many patients go on to have 1 persistent pain and psychological distress after trauma ; however, we do not know the incidence of these outcomes following traumatic musculoskeletal injury (TMSI). Thus the aims of this ongoing pilot study are (1) to determine the incidence of acute pain while in hospital and persistent pain at 3months following TMSI, and (2) to examine the associations between pain, anxiety, and depressive symptoms during hospitalization. Methods: This study was approved by Sunnybrook HSC IRB. We used a prospective, longitudinal design to follow participants up to 3 months after injury. Inclusion criteria were: >17 years, sustained a TMSI; trauma admission and length of hospital stay (LOS) ≥2 days. Participants with Glasgow Coma Scale motor ≤ 5, spinal cord damage, burns, or self-injury, or who had a mechanical fall were excluded. Participants were followed during hospitalization (T1) and at 3-months (T2) post TMSI. Participants provided demographic information, as well as reliable and valid measures of pain, function, disability and psychological distress. Statistical analyses included descriptive analyses, paired t-tests, and correlations. Results: The initial sample comprised 53 participants (67.9% male) with a mean age of 46.6 years (SD=19.22). The average Injury Severity Score was 17.6 (SD=8.02) and length of stay was 14.5 days (SD=20.12). 35% (n=19) of participants reported pre-injury conditions (e.g., asthma, diabetes, chronic pain) and an overall health rating of 3.04 (SD=0.99, range 1-5) on a scale of 0- poor health to 5excellent health. Attrition rate was 46% with n= 34 completing the 3-month follow-up. Significant differences were not found on demographic measures between those who completed the 3-month follow-up and those who did not. 92.5% (n=49) and 85.0% (n=29) of participants reported pain while in hospital and at 3 months, respectively. Pain scores (0-10 numeric rating scale) decreased significantly from T1 (Mean=4.7, SD=1.86, Median=5, Range 0-10) to T2 [(Mean= 3.01; SD = 2.34, Median=2, Range 0-10); t(31) = 4.00, p=.000] as did pain disability [T1 (M = 6.80, SD = 2.44); T2 [(M = 3.46, SD = 2.73); t(30) = 6.24]. T1 pain intensity was significantly correlated with T1 anxiety (r =.470, p=.000), depression (r =.362, p=.008), anxiety sensitivity (r =.281, p=.043), fear and anxiety related responses to pain (r =.370, p=.007), self-efficacy in managing pain (r =-.319, p=.021) and posttraumatic stress symptoms (r =.345, p=.012). Discussion: The preliminary results indicate the high incidence of pain following TMSI and point to an association between anxiety, depression, and pain during the in-hospital stay. With additional participant recruitment into this ongoing study, and appropriate statistical power, we will identify the risk and protective factors associated with the development of persistent pain 3-months after TMSI. Funding disclosure: Nothing to disclose. Reference: 1. Rosenbloom BN, Khan S, McCartney C, Katz J. Pain and Psychological Outcomes Following Traumatic Musculoskeletal Injury. Journal of Pain Research. 2013;6:39-51. A144 A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL TO EVALUATE THE ® EFFICACY AND SAFETY OF THE SUFENTANIL NANOTAB PCA SYSTEM/15MCG FOR POSTOPERATIVE PAIN IN PATIENTS AFTER ABDOMINAL SURGERY 1 2 3 4 5 F.G. Ringold , H. Minkowitz , T.-J. Gan , K. Aqua , P.P. Palmer , M.A. Royal 1 5 2 Surgery, Surgical Associates of Mobile, Mobile, AL, Anesthesiology, Memorial Hermann Memorial 3 City Hospital Medical Center, Houston, TX, Anesthesiology, Duke University Medical Center, 4 Durham, NC, Obstetrics-Gynecology, Atlantic Clinical Research Collaborative, Boynton Beach, FL, 5 Clinical, AcelRx Pharmaceuticals, Inc., Redwood City, CA, USA Introduction: The Sufentanil NanoTab PCA System (SNPS) is a novel preprogrammed noninvasive product candidate in Phase 3 development that dispenses small (3 mm diameter) sufentanil 15 mcg microtablets sublingually with a 20-minute lockout period. Sufentanil is an opioid approved as an IV formulation for the induction and maintenance of anesthesia and for labor epidural use. It possesses a high therapeutic index with minimal respiratory depressive effects relative to its analgesic effect in animal studies, a low incidence of cardiac instability and minimal pharmacokinetic differences based on age, liver or kidney function. While these attributes could be ideal in a post-operative opioid analgesic, its rapid redistribution from plasma following IV administration and short duration of action make it less than ideal for intravenous patient-controlled analgesia (IV PCA). IV PCA, particularly with morphine, is commonly used for the management of moderate-to-severe post-operative pain. However, its use is associated with limitations, including the use of low therapeutic index opioids, the risk of pump programming errors and reduced patient mobility due to IV tethering. Materials/Methods: This randomized, double blind, placebo-controlled Phase 3 study was performed as one of two pivotal studies required for FDA approval of SNPS. The study objectives were to compare the safety and efficacy of SNPS to placebo delivered via the SNPS device for the management of moderate-to-severe post-operative pain after open abdominal surgery. Up to 180 post-operative inpatients (18 years and older) who were expected to require parenteral opioid analgesia for at least 48 hours after surgery were to be randomized (120 patients in SNPS 15 mcg group and 60 patients in placebo group) to ensure at least 159 total patients (106 in the SNPS group and 53 in the placebo group), who received study drug and provide primary efficacy data (90% power) for analysis. The primary efficacy variable was the time-weighted summed pain intensity difference over the 48-hour study period (SPID-48) using an 11-point numerical rating scale. Key secondary efficacy variables included pain intensity and pain relief scores (5-point categorical scale) over the study period, patient global assessments of method of pain control (4-point categorical scale), patient and nurse ease of care scores (using a validated Ease-of-Use questionnaire), and rescue medication consumption. Safety assessments included spontaneous adverse reaction reports, vital signs, medical history, physical examinations, oxygen saturation measurements, and concomitant medication usage. Results: The first patient in for the study occurred on March 6, 2012 and last patient out occurred on January 12, 2013. A total of 214 patients were screened and 178 were randomized. There were a total of 36 screen failures. At the time of this abstract submission, data analysis was in process. Full data will be available at the time of the meeting and presented in the poster. Conclusion: The Sufentanil NanoTab PCA System provides an attractive alternative to traditional IV PCA analgesia, is easy for healthcare professionals to set-up and for patients to use. Upon completion of the required Phase 3 studies, a new drug application will be submitted to FDA for review. A145 ® SUFENTANIL NANOTAB PCA SYSTEM: RESULTS FROM THREE HUMAN FACTORS STUDIES P.P. Palmer, B.N. Dasu, M.A. Royal 1 2 Clinical, Engineering, AcelRx Pharmaceuticals, Inc., Redwood City, CA, USA Introduction: Intravenous patient-controlled analgesia (IV PCA) is standard of care in many hospitals for managing post-operative pain. It is often associated with limitations, including use of low therapeutic index opioids, programming errors, reduced patient mobility and infiltrated IVs. The ® Sufentanil NanoTab PCA System (SNPS) is a novel, non-invasive, preprogrammed approach to patient-controlled sublingual analgesia currently in development that avoids the issues of medication and programming errors which occur with IV PCA. Patients can utilize the System to deliver 15 mcg sufentanil tablets sublingually with a 20-minute lockout between doses. Two randomized, controlled Phase 2 studies, an open-label Phase 2 device functionality study, and a randomized Phase 3 noninferiority trial vs. IV PCA morphine have demonstrated that sublingual delivery of sufentanil is efficacious and well tolerated in treating moderate-to-severe post-operative pain after major surgery. Two, randomized, placebo-controlled Phase 3 trials are ongoing. Materials/methods: Human factors (HF) studies are an important aspect of device development to allow end-user feedback on system design features, functionality, and usability. Three SNPS HF studies are discussed. Farm Design co-developed the test protocol and moderated the sessions. During the training portion and post-test interview, the moderator and nurse sat at a table equipped with system components, a box containing all System components and a copy of the instructions for use (IFU) guide for the nurse to use during the review and practice session. Results: HF Study 1 involved 19 nurse and central sterile/biomedical engineer participants without prior System training to assess the IFU guide for comprehension. HF Study 2 involved 15 nurse participants who were experienced in setting up PCA pumps. HF Study 3 included 15 nurses and 15 healthy adults (mean age 61.5 years) who simulated patient interactions in a study evaluating 15 nurse-”patient” pairs. Sessions were conducted over 7 days. All of these participants were from Northern California and all “patient” participants were at least high school graduates and six had had prior surgery. Of the 30 total nurse participants who were trained in system use in HF studies, onethird used reading glasses. Testing mimicked a “worst case” scenario in that participants only had one chance to set up the SNPS before being evaluated on 10 separate tasks related to the system's primary operating functions. After a short period of training, all nurses completed the 10 tasks with little help and all patients completed 3 tasks with little help. No task rated lower than a 4.1 on a 5-point categorical ease-of-use scale. Nearly all participants said that they would have no trouble using the SNPS once they were used to it. Participants said that the user interface was so easy to follow that they did not need to refer to the IFU. Conclusion: Based on the results from these studies, it appears that the Sufentanil NanoTab PCA System is an easy to use and relatively intuitive device. Additional HF studies are planned using pharmacists, physicians and adults with hearing and visual impairment. A146 ® SUFENTANIL NANOTAB PCA SYSTEM: MECHANICAL AND SOFTWARE DESIGN FEATURES 1,2 1 P.P. Palmer , B.N. Dasu , M.A. Royal 1 1 2 Clinical, AcelRx Pharmaceuticals, Inc., Redwood City, Anesthesiology, University of California, San 3 Francisco, San Francisco, Engineering, AcelRx Pharmaceuticals, Inc., Redwood City, CA, USA Introduction: Intravenous patient-controlled analgesia (IV PCA) is commonly used to manage postoperative pain. However, it is associated with limitations, including programming errors and reduced patient mobility. Sufentanil is an opioid approved for IV and epidural administration. While it possesses a high therapeutic index with minimal respiratory depressive effects relative to its analgesic effect, high cardiac stability and minimal pharmacokinetic differences based on age, liver or kidney function, its rapid redistribution from plasma following IV administration and short duration of action make it less than ideal for IV PCA. The Sufentanil NanoTab PCA System is a novel preprogrammed noninvasive product in Phase 3 development designed to deliver sublingual sufentanil 15 mcg microtablets with a 20-minute lockout period. Methods: Issues with IV PCA delivery of opioids were assessed and categorized. Design of the Sufentanil NanoTab PCA System was focused on features to avoid or minimize these identified issues. Four human factors and ease-of-use studies were conducted to optimize design functionality and obtain user feedback on features and usability of the Sufentanil NanoTab PCA System. System functionality and usability were then tested in 3 Phase 3 studies in hospitalized patients with moderate-to-severe pain after major surgery. Results: The device is comfortable when held and easy for patients to handle and operate. The preprogrammed device (fixed dose and lockout interval) eliminates programming errors. A screen provides easy to follow set-up steps for the nurse and bedside patient training. Tones and indicator lights confirm successful dose administration to the patient. An accelerometer assists with proper orientation of the device for sublingual dosing. A radiofrequency identification (RFID) tag worn by the patient pairs the device to a unique patient to reduce the potential for proxy dosing. A steel cable tether locks the device to the bedside or wheelchair to prevent diversion. The device tracks dose attempts and successful deliveries to help assess patient proper use and understanding. All data can be downloaded for reconciliation audits and for patient medical records. The device's battery is designed to last up to 72h and is easily recharged between uses. Conclusion: PCA pumps are commonly used to manage postoperative pain, however their use is associated with limitations: 1 Risk of programming errors 2 Risk of analgesic gaps due to IV problems or pump malfunctions Reduced patient mobility due to tethering to IV line and pole-mounted pump 3,4 Risk of proxy dosing by someone other than the patient The Sufentanil NanoTab PCA System is designed to address these limitations: Preprogrammed device eliminates programming errors which can occur with IV PCA System screen prompts designed to facilitate proper setup and use RFID tag and locking tether reduces the potential for proxy dosing and diversion Sublingual route of delivery avoids IV-related complications A147 CONTINUOUS REGIONAL ANALGESIA AFTER ORTHOPEDIC FOOT SURGERY: COMPARISON OF COSTS AND STANDARDS OF CARE IN OUTPATIENT VERSUS INPATIENT MANAGEMENT 1 2 2 3 1 4 A. Saporito , S. Calciolari , L. Gonzalez Ortiz , E. Sturini , G.J. Petri , A. Borgeat , J. Aguirre 1 4 2 Anesthesiology, Bellinzona Regional Hospital, Bellinzona, Faculty of Economics, University of Italian 3 4 Switzerland (USI), Lugano, Anesthesiology, St. Chiara Clinic, Locarno, Orthopedic, Bellinzona 5 Regional Hospital, Bellinzona, Anesthesiology, Uniklinik Balgrist, Zurich, Switzerland Background: Exploding health related costs require a reorganisation of perioperative clinical processes in a more cost-effective way. Outpatient postoperative continuous regional analgesia after ambulatory orthopedic surgery has been described as a safe and effective practice. It could also lead to a reduction in hospital fix costs, but the risks of both quality of care decrease and costs shifting to patients should be avoided. Aim of this study is to compare costs and standard of care in orthopedic foot surgery patients treated with a continuous popliteal block in hospital and at home. Method: After ethical committee approval, a case-control prospective study was conducted on two continuous cohorts of patient, undergoing orthopedic forefoot surgery with a continuous popliteal block managed either with a 72 hours long hospital stay or on an ambulatory basis (patients were left free to decide their allocation). Both groups were treated with an ultrasound guided popliteal block with mepivacaine 1.5% 20 ml, followed by a perineural infusion of ropivacaine 0.15% 5 ml/h through an elastomeric pump. Patients were monitored by trained anesthetic nurses with the same follow-up protocol either in hospital or at home by phone, in order to assess pain levels (NRS) and eventual complications. Exclusion criteria were: patients refusal, allergy to local anesthetic, infections in the popliteal fossa. We analysed the variability of costs through three different multiple regression models with logarithmically transformed costs per patient as dependent variable (acute costs, post-acute costs, and social costs, separately), the three models controlling for demographic (gender, age) and clinical (main pathology, comorbidities) factors. Results: A total of 163 patients were included (133 inpatient vs 30 outpatient). The two groups were not statistically different with regard to population characteristics (sex, age, ASA class). Only 3.3% of subjects in the day-hospital group had post-operative complications, versus 8.3% in the inpatient group (the more frequent being persistent motor block), but this difference was not statistically significant. The average total acute costs per patient equals 4,975±1,889 CHF. The intra-operative phase accounts for 36.40% of the overall costs, while the post-intervention phase and the indirect costs account for 27.36% and 31.34% respectively. Pharmaceuticals costs represent 68.17% of total costs, followed by readmission costs (19.90%). The inpatient group showed significantly higher average costs for all these categories. With regard to social costs, patients' interruption costs and unpaid informal care had the highest incidence (respectively 71.65%, and 30.93%). Patients treated in dayhospital were not associated with significantly different post-acute costs compared to inpatient cases (p=0.07). Conclusion: Outpatient continuous regional analgesia after orthopaedic foot surgery remains costeffective even when costs related to complications and unexpected readmissions or adjunctive ambulatory visits are taken into account. Its cost-effectiveness does not seem to be based on a costs shifting toward patients. A148 A RANDOMIZED COMPARISON OF INTERSCALENE BLOCK AND COMBINED SUPRASCAPULAR NERVE BLOCK AND AXILLARY NERVE BLOCKS FOR POSTOPERATIVE PAIN RELIEF IN ARTHROSCOPIC SHOULDER ROTATOR CUFF REPAIR R. Sharma, S. Dhir, S. Ganapathy Anesthesia, St. Joseph Health Care, London, ON, Canada Objective: Primary objective of this study is to prospectively compare and evaluate efficacy as well as note side effects of Interscalene block (ISB) and combined Suprascapular nerve block (SSB) and Axillary nerve block (ANB) for Arthroscopic shoulder rotator cuff repair (ARCR). We are testing the hypothesis that SSB combined with ANB provides similar postoperative analgesia and patient satisfaction when compared to ISB after ARCR. Material and methods: Patients having elective ARCR are randomized to one of the two groups. Group 1: receives ISB. Group 2: receives SSB and ANB. Both block groups will be ultrasound guided and nerve stimulator aided followed by a general anesthesia. Performance time, quality and efficacy as well as any side-effects of the blocks will be evaluated in terms of pain scores in recovery room, after 4- 6 hours and the next morning. Opioid usage and patient satisfaction will also be noted. Results: These are the results of a pilot study of 7 patients. The main study is ongoing with 30 patients in each group. The results are in the table below: Group 1 Group 2 Time for block performance (min±SD) 3.5±0.58 6.67±0.58 Sensory block onset (min±SD) 12.5±6.45 18.33±10.4 Motor block onset (min±SD) 16.25±8.54 26.67±5.78 VAS in PACU (min±SD) 2 7.67 VAS at 4-6 hrs 1.5 6.67 VAS at 24 hrs 5.7 5 VAS at 7 days 1.3 1 Satisfaction score (PACU) 9.5 5 Satisfaction score(4-6 hrs) 9.5 6.67 [Results] Group 1 Group 2 Satisfaction score (24 hrs) 10 6.33 Satisfaction score (7 days) 10 6.33 [Results] Conclusion: On analysis of the pilot data, both the block groups had similar time durations in block performance and onset of sensory and motor block. The pain scores were significantly higher and the satisfaction scores significantly lower for group 2. Further data on the ongoing study will reveal the effectiveness of the 2 blocks in a larger group of subjects. 1. Lee SM, Park SE, Nam YS, Lee KJ, Kwon MJ. Analgesic effectiveness of nerve block in shoulder arthroscopy: comparison between interscalene, suprascapular and axillary nerve blocks. Knee Surg Sports Traumatol Arthrosc (2012)20:2573-2578. 2. Chan CW, Peng PWH. Suprascapular nerve block. Reg Anesth Pain Med 2011;36:358-373. 3. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anesthesia, 2010, 65, pages 608-624. 4. Singelyn FJ, Lhotel L, Fabre B. Pain relief after Arthroscopic shoulder surgery: A comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth Analg 2004;99:589-92 A149 ULTRASOUND-GUIDED PARAVERTEBRAL REGIONAL ANESTHESIA IN BUFFALO M.M. Shokry, E.A. Berbish Veterinary Surgery, Anesthesiology & Radiology, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt th Adequate flank regional anaesthesia was achieved using ultrasound-guided nerve block of the 13 st nd thoracic, 1 and 2 lumbar spinal nerves after their exits from their intervertebral foraminae with only 5 ml of lidocaine 2%. Twelve successful trials were conducted on 4 buffaloes without any complications. Introduction: In the last recent decades, utilization of ultrasound (US) to guide needle placement during spatial nerve block is now well established in human patients (Harmon and Hearty, 2007;) .Paravertebral regional block (PRB) has been the anesthetic method of choice for surgical procedures as laparotomy , rumenotomy and caesarean section involving the flank region in buffaloes (Said, Shokry and Fouad, 1967). However, with reference to age and size , the difficulty to establish reliable th st nd landmarks of the target spinal nerves (13 thoracic, 1 and 2 lumbar nerves) supplying the flank region, was the reason to conduct this study. Materials and methods: The previous anatomical study of the flank region in buffaloes by (Said, Shokry and Fouad, 1976) has been taken as a reference for ultrasound tracing of the paravertebral th st nd nerves supplying the flank region i.e. the 13 thoracic, 1 and 2 lumbar spinal nerves at their exits from the intervertebral foraminae. This study was conducted on 4 buffaloes (2 adults and 2 calves). On them, 12 ultrasound-guided paravertebral nerve block trials were performed. A 20-gg 12 ml spinal needles were also used in the procedure. Ultrasound images were presented as a single sagittal th st plane with slight posterior tilting. For the 13 thoracic nerve, in between the last thoracic and the 1 st nd lumbar transverse processes,just behind the last rib and for the 1 and 2 lumbar nerves, in between the succeeded lumbar transverse processes was , lateral to the midline. 5 ml of lidocaine 2% were injected in the vicinity of each nerve trunk. Results: Satisfactory anaesthesia of the left flank region was achieved within 2 minutes after injection and lasted for 120 minutes. Compared with landmark-based technique, using of ultrasound greatly improved the success rate of regional flank analgesia with minimal amounts of local anaesthetic. No complications were recorded with all trials. Discussion: Successful analgesia of the flank region in water buffalo was accomplished in all trials following US-guided paravertebral blocks. The doses and concentration of the local anaesthetic ( 5 ml of 2% local anaesthetic) were very low in comparison with the doses and concentration used in routine blind injection (20 ml of 5% local anaesthetic) (Said et al, 1976). In this respect, US-guided nerve block is routinely used with great success in human patients ( Harmon and Hearty, 2007). References: Hamon, D. and Hearty, C. Ultrasound-guided suprascapular nerve block Technique Pain Physician. 2007, 10, 743-746. Said, AH., Shokry,MM. and Fouad,K. Paravertebral Anaesthesia in Buffaloes Zbl.Vet.Med.A, 1976, 23, 85-88. A150 THE CUTANEOUS BRANCH OF THE SAPHENOUS NERVE - AN ANATOMICAL VARIANT S. Singeetham, D. Auyong Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA Saphenous nerve blocks can provide anesthesia to the knee and medial lower extremity. Anatomically, this nerve branches from the femoral nerve and courses through the anterior thigh in the adductor canal. It continues as a superficial nerve distal to the knee and terminates as sensory fibers supplying the medial leg. The adductor canal block, which anesthetizes the saphenous nerve, has increased in popularity because it is associated with a minimal decrease in quadriceps motor 1 strength while providing analgesia after knee surgery . Objective assessment of adductor canal block 2 success is primarily limited to sensory testing of the medial leg saphenous nerve distribution . Examination of the adductor canal shows that the saphenous nerve exits the adductor canal posterior to the vastoadductor membrane. The vastoadductor membrane connects the vastus medialis and the adductor muscles to form the “roof“ of the adductor canal(Image 1). Cutaneous branches of the 3 saphenous nerve can perforate the vastoadductor membrane . Most commonly, the cutaneous branch splits from the saphenous nerve distal to the adductor canal and innervates the medial knee 4 and lower leg as the cutaneous saphenous branch . Therefore, saphenous nerve blockade assessment from an adductor canal block is performed by examining sensation of the medial lower leg. During a fresh tissue cadaver dissection, we identified a variant of the cutaneous branch of the saphenous nerve exiting 6cm caudal to the femoral crease, proximal to the adductor canal. This superficial branch coursed anterior to the femoral artery then medial to the sartorius muscle. It continued in the superficial plane medial to the knee and then to the lower leg as the cutaneous branch of the saphenous nerve(Image 2). The subsartorial region was dissected to expose the adductor canal including the vastus medialis, adductor magnus, femoral artery, saphenous nerve and vastoadductor membrane. No portion of the saphenous nerve from the adductor canal could be identified coursing distal to the knee joint. Thus, the only superficial cutaneous branch of this subject's saphenous nerve did not course through the adductor canal. This variant has at least two important clinical correlates: 1) The cutaneous branch of the saphenous nerve may not always course through the adductor canal. Therefore, the adductor canal block may not effectively provide anesthesia to the distal medial lower leg in all subjects; and 2) Intact sensation of the medial lower leg does not rule out an effective adductor canal block if analgesia to the knee is the desired outcome. Low “success” rates of saphenous nerve blocks in the literature may be a reflection of anatomic variation. Further studies are necessary to ascertain the rate of saphenous nerve variants. [IMAGE 1] [IMAGE 2] References: 1. Anesthesiology (2013) 118:409-415. 2. Anesthesiology (2005) 102:633-638. 3. RAPM (2011) 36:399-402. 4. Surgical and Radiologic Anatomy (2007) 29:569-573. A151 ULTRASOUND IDENTIFICATION OF GREATER PALATINE FORAMEN AND US GUIDED GREATER PALATINE NERVE BLOCKS: A CADAVERIC STUDY N. Sahar Hafeez, R. Sondekoppam Vijayashankar, S. Ganapathy, M. Johnson, P. Merrifield, K.A. Galil 1 2 Anatomy, University of Western Ontario, Anesthesiology and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada Introduction: The greater palatine nerve block is commonly performed for maxillary and palatal anesthesia by utilising bony landmarks like second or third molars by blind injections. The bony landmarks are inconsistent in location leading to multiple attempts, failure or partial blockade. We hypothesise that utilisation of ultrasound can consistently identify greater palatine foramen into which US guided injections can consistently deposit the drug around the greater palatine nerve. Materials and methods: 20 undissected well-embalmed hemi-sectioned cadaveric heads were used for the study after ensuring the intactness of hard palate mucosa and ruling out major anatomical malformations. After applying ultrasound gel over the cleaned mucosal surface, a linear high frequency hockey stick probe (7-13MHz, Sonosite M-Turbo, Sonosite, Bothell, WA) was positioned through the mouth in long axis to the hard palate laterally to identify dental structures as intermittent peaks. The probe was then moved medially until visualization of the hard palate as a continuous hyper-echoic line. The discontinuity in this line closer to the 3rd molar was identified to be the greater palatine foramen. [US image of Greater palatine foramen] The probe was positioned so that US guided injections of 0.1ml India ink were made in an oblique plane while maintaining the GPF in the centre of the screen. Each specimen was dissected immediately after the injection to look for the distribution of the dye in relation to greater palatine nerve, greater palatine foramen and greater palatine canal. Success rate of identification of GPF was the primary objective. The number of needle pass and success rate of injections at the GPF was also calculated. The cases were termed failure if the foramen was not identified with 2 attempts at scanning. Results: Greater palatine foramen was successfully identified in all the 16 hemi-sectioned heads (100%) although 4 (25%) cases required more than one attempt for identification. The identification of GPF was successful in edentulous cadavers also. In one case (6.25%), the greater palatine foramen was identified as a step like defect in the hard palate with the foramen pointing anteriorly. In 7 out of 16 hemi-sectioned cadaveric specimens (43.75%), needle pass was seen on the US and traces of India ink were found within the Greater palatine canal and pterygopalatine fossa. In the rest of the 9 specimens, although the injections were made after successful identification of GPF, the needle of the syringe could not be visualised entering the foramen and the dye was observed in the mucosal tissue of the hard palate anterior to the GPF. In two specimens, traces of dye were found in the tissue of soft palate (1.25%). Conclusion: Ultrasound has the potential to successfully locate GPF and its variations in normal and edentulous maxilla. The performance of US guided greater palatine nerve blocks in living patients might be easier due to better echogenicity of tissues than in embalmed cadavers and by the ability to identify accompanying artery by ultrasound. Ultrasound has the potential for application in dental blocks like greater palatine nerve blocks. A152 THE CHANGES AND FUNCTION OF MICRORNA 23B IN SPINAL CORD IN THE SPINAL NERVE LIGATION MODEL OF NEUROPATHIC PAIN P.-H. Tan, C.-C. Liu 1 2 Anesthesiology, E-DA Hospital/I-Shou University, Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan R.O.C. Introduction: Neuropathic pain resulting from nerve lesions or dysfunction represents one of the most challenging neurological diseases to treat. microRNAs (miRNAs) are small noncoding transcripts that can control expression of protein-coding mRNAs at the posttranscriptional level and play an important role in regulating synaptic plasticity. Significant up-regulation of miRNA-23b in spinal cord was noted in our microarray miRNA profiling in neuropathic pain. Previous study found the involvement of miR-23b in the regulation of mouse µ opioid receptor(1,2). We hypothesized the upregulation of mir-23b play a role in the induction of neuropathic pain. Thus, in this study, we examined the antinociception produced by inhibition of mir-23b in spinal cord for neuropathic pain. Material and methods: Spinal nerve ligation (SNL), a model of neuropathic pain, was performed to induce neuropathic pain. In treatment groups, 2 nmole locked nucleic acid (LNA) LNA-mir-23b inhibitor or scrambled LNA-mir-23b inhibitor were administered 3 days after SNL. Behavioral tests were performed before or 5 days and 10 days after injection of LNA-mir-23b inhibitor or scrambled LNA-mir-23b inhibitor. The spinal cord was dissected for analysis of mir-23b after behavioral test performed at 5 and 10 days after injection of LNA-mir-23b inhibitor or scrambled LNA-mir-23b inhibitor. Rats received SNL only were assigned to be another control group. The spinal cord was dissected for analysis of mir-23b 3 days after SNL. The analysis of mir-23b was preformed by quantitative real-time polymerase chain reaction and in-situ hybridization. Results: Significant increase of mir-23b was noted in spinal cord of rats received SNL only. Intrathecal injection of 2 nmole LNA-mir-23b inhibitor could effectively diminish SNL-induced allodynia and thermal hyperalgesia on day 5 and day 10 after injection of LNA-mir-23b inhibitor. The expression of miRNA-23b in spinal cord was significant decreased on day 5 and 10 after injection of LNA-mir-23b inhibitor compared with rats received SNL alone. Conclusions: This study provides evidence that SNL induces up-regulation of mir-23b in spinal cord and inhibition of mir-23b produces antinociceptive effect for neuropathic pain. References: 1. Wu Q, Law PY, Wei LN, Loh HH (2008) Post-transcriptional regulation of mouse mu opioid receptor (MOR1) via its 3' untranslated region: a role for microRNA23b. FASEB J 22:4085-4095. 2. Wu Q, Zhang L, Law PY, Wei LN, Loh HH (2009) Long-term morphine treatment decreases the association of mu-opioid receptor (MOR1) mRNA with polysomes through miRNA23b. Mol Pharmacol 75:744-750. Funding: This work was supported by National Science Council Grant NSC 100-2314-B-214-002MY3 and NSC 101-2321-B-214 -001, Taiwan. A153 CAN PARALLEL USE OF REGIONAL BLOCK ROOM SHORTEN THE ANESTHESIA UTILIZATION TIME IN ORTHOPEDIC SURGERY? S. Tangwiwat, A. Iamaroon, A. Lurngnateetape, K. Chareancholvanich, C. Nuntawinit 1 2 3 Anesthesiology, Orthopedic Surgery, Nursing Siriraj Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Introduction: Application of regional anesthesia (RA) can be time consuming, thus interfering with surgical schedule. We hypothesized that running a block room parallel to the operating rooms for performing RA reduces the anesthesia utilization operating room(OR) time in orthopedic surgery, thus increasing efficiency of daily schedule. Material and methods: After Institutional Review Board (IRB) approval, a prospective study was performed from January till June 2012 including orthopedic operations without spine surgery. Parallel to the ORs a special 'block room' was run by an anesthetic team to apply selective or additional (to GA) RA procedures. The following data were recorded: demographic characteristics, anesthesia techniques, RA location, anesthesia utilization time before and after surgery, surgical preparation time, operation- and turnover time. We also recorded the first case on-time start (9 AM) and the number of cases running after 4 PM. Results: Of 1,726 orthopedic procedures, 883 (51.2%) had RA, 288 (16.7%) combined GA + RA and 555 (32.2%) GA alone. RA was performed in either the block room (21.5%) or the OR (71.8%) or both locations (6.7%). Compared to the usual schedule the availability of a block room significantly reduced the anesthesia utilization time but not the turnover time as shown in the Table. On-time start (9:00AM) of the first case was only 38%. Cases running after 4 PM were 3.7 (mean) per day and 50% of overutilized OR time cases were finished at 4 to 5 PM. Anesthesia techniques Time ( min)/case Median (IQ range) GA RA in OR RA in block room GA+ RA Anesthesia preprocedure time 15 (10-25) * 5 (5-5) 25 (20-35) * Anesthesia postprocedure time 5 (5-10)** 5 (3-5) 5 (3-5) 5 (5-10) ** Anesthesia Pre + post time 25 (18-35) *** 25 (20-35)*** 10 (8-14) 35 (25-45)*** Surgical preparation time 15 (10-20) 20 (15-25)**** 15 (10-25) 15 (10-25) Surgical time 55 (25-100)+ 100 (70-125) 90 (65-115) 104 (70-145)+ Turnover time 10 (5-15) 10 (5-15) 5 (5-10) 10 (5-15) *, **, ***, ****, + = P < 0.05 when compared to RA in block room [Table] Discussion: Using a block room as additional workstation resulted in reduced perioperative anesthesia-controlled time. RA procedure in OR is time-consuming. Time usage for RA in OR was longer than GA. Turnover time was unaffected by anesthetic techniques. Future studies should investigate if using a block room can improve the OR time efficiency. References: 1. Mariano ER, Chu LF, Peinado CR, Mazzei WJ. Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia. J Clin Anesth 2009 ;21(4):253-7. 2. Armstrong KP, Cherry RA. Brachial plexus anesthesia compared to general anesthesia when a block room is available. Can J Anaesth 2004 ;51(1):41-4. 3. Eappen S, Flanagan H, Lithman R, Bhattacharyya N. The addition of a regional block team to the orthopedic operating rooms does not improve anesthesia-controlled times and turnover time in the setting of long turnover times. J Clin Anesth 2007 ;19(2):85-91. Funding: Research grant of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand Personal conflicts of interest disclosure: Nothing to disclose A154 EFFICACY AND SAFETY OF THREE DIFFERENT APPROACHES FOR ULTRASOUND GUIDED FEMORAL NERVE BLOCK FOR PATIENTS UNDERGOING TOTAL KNEE ARTHROPLASTY A. Tharian, S. Gonzales, N. Niemiec, S. Saatee, R. Omar, R. Sauer, L. Chupatanakul, K.D. Candido, N.N. Knezevic 1 2 Anesthesiology and Pain Medicine, Advocate Illinois Masonic Medical Center, Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Introduction: Total knee arthroplasty (TKA) causes considerable postoperative pain. It can prolong hospitalization, impair rehabilitation and early mobilization, and may worsen functional outcome. Effective postoperative pain control following TKA lowers the risk of postoperative complications, such as thromboembolic disease and nosocomial infection. Patient-controlled IV analgesia with opioids is associated with side effects (nausea, vomiting, pruritis, ileus, urinary retention, sedation and respiratory arrest), which could delay the initiation of physical therapy. Femoral nerve blocks (FNB) have been shown to significantly improve postoperative analgesia and have less side effects as compared with opioid therapy. Objective: The purpose of this prospective, single blinded, randomized study was to determine efficacy and safety of three different approaches for ultrasound guided FNB: single-shot femoral nerve block (SFNB), continuous femoral nerve block (CFNB) with non-stimulating catheter, and CFNB with stimulating catheters. Material and Methods: We enrolled 53 patients (ages 18-90 years) undergoing TKA in this pilot study. All patients were randomly assigned to one of three groups (SFNB, CFNB with non-stimulating catheter, and CFNB with stimulating catheter). We excluded patients who had redo surgery on the ipsilateral knee, radicular pain in the same leg, BMI ≥45, allergy to local anesthetics, opioid habituation, neuropathy of any etiology in the surgical extremity or any contraindications to regional block. All blocks were performed under ultrasound guidance combined with neural stimulation. All patients were evaluated in the PACU at arrival (time 0), 30 minutes and 1 hour after arrival in the PACU, and then at 12, 24 and 48 hours after the surgery. All patients were assessed for ability to move the knee, numeric pain scores, amount of supplemental pain medications and overall satisfaction of the patient with pain control. Results: There was no statistically significant difference between these three groups with respect to age, gender, height, weight, total block time, total surgery time or needle depth (p>0.05). [Table1] From our preliminary results, patients from CFNB with non-stimulating catheters had better pain relief at rest (at 24 and 48 hours) and during the movement (30 minutes, 1 hour, 12 hours) as compared with SFNB and CFNB with stimulating catheters. There was no statistically significant difference in amount of PCA opioid consumption during the 48 hours after surgery. [Figure] Conclusion: Single-shot femoral nerve block (SFNB) and continuous femoral nerve block (CFNB) comprise the two main peripheral blocks used in contemporary practice for TKA. Stimulating catheters are sometimes used in CFNB with the presumption that they aid in placing the catheter closer to the targeted nerve thereby providing superior analgesia. There have been studies showing the benefit of SFNB and CFNB individually, comparing SFNB and CFNB, as well as comparing stimulating and nonstimulating catheters in CFNB. However, this is the first study comparing all three techniques in relation to postoperative pain control and rehabilitation, showing slightly better results with nonstimulating CFNB. A longer follow up and the enrollment of more patients will clarify statistical and clinical significance. A155 PRELIMINARY REPORT: RETROSPECTIVE REVIEW OF DURATION OF SINGLE SHOT POPLITEAL SCIATIC NERVE BLOCKS FOR FOOT AND ANKLE SURGERY J. Thomas, J. Li, F. Dai, R. Wardhan Anesthesiology, Yale University, New Haven, CT, USA Introduction: Real time ultrasound guidance for popliteal sciatic block is considered to be a successful technique for providing anesthesia/analgesia for foot and ankle surgery. Ultrasound guidance results in higher success, faster onset, and progression of sensorimotor block, without an increase in block procedure time, or complications when compared to nerve stimulation only. Method: Ultrasound guided single shot popliteal sciatic blocks are routinely performed in our institute on patients undergoing ankle and foot surgery. We used our perioperative database to identify all patients who underwent ankle and foot surgery performed by one surgeon from July 2011 through December 2012. This is a retrospective database study and these results constitute an interim analysis. The information collected includes gender, age, volume of local anesthetic used, duration of nerve block & postoperative pain scores. Results: After IRB approval for chart review, 53(29 females,24 males) ASA I-III patients were analyzed.All patients underwent an ultrasound guided popliteal sciatic block utilizing varying volumes of 0.5% ropivacaine. Average duration of block was 22(7-3)hrs.No statistically significant (negative correlation via Spearman rank correlation coefficient = -0.13, p-value = 0.38) was observed between duration of block (hrs.) and volume of Ropivacaine 0.5% (ml) in these 53 patients. Discussion: Many studies have been performed to determine the effect of volume vs. concentration on the onset and duration of various nerves. Latzke et al even determined the minimum effective volume of local anesthetic required to block sciatic nerve, however confusion still exists on whether higher volume or concentration results in longer duration of sciatic nerve block .The goal of this study is to retrospectively ascertain duration from commonly used volumes by regional anesthesiologists. Latzke D, Marhofer P, Zeitlinger M, Machata A, Neumann F, Lackner E and Kettner S C 2010 Minimal local anaesthetic volumes for sciatic nerve block: evaluation of ED 99 in volunteers Br J Anaesth 104 239-44 Perlas A, Brull R, Chan V W, McCartney C J, Nuica A and Abbas S 2008 Ultrasound guidance improves the success of sciatic nerve block at the popliteal fossa Reg Anesth Pain Med 33 259-65 A156 USE OF IMPEDANCE AS A TOOL TO RECOGNIZE INTRANEURAL NEEDLE PLACEMENT: A STUDY EXTRAPOLATING CADAVER FINDINGS TO MEASUREMENTS IN AMPUTATED LIMBS 1 1 1 1 1 2 A. Vydyanathan , M.V. Tu , S. Nair , S. Huch , Z. Khan , A. Kaufman , N. Shaparin 1 1 Anesthesiology and Pain Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 2 New York, NY, Anesthesiology and Pain Medicine, UMNDJ Robert Wood Johnson Hospital, Newark, NJ, USA Introduction: Injury to peripheral nerves is a very rare but devastating complication of peripheral nerve blocks. While the incidence is 4-10/1000 nerve blocks, most of these injuries are transient but a few are permanent and disabling (1). While the use of ultrasound has revolutionized the field of regional anesthesia, it has not been shown to improve safety and prevent intraneural injections (2). The use of electrical stimulation with the standard of amperage >0.2 mA as preventing intraneural placement is also questionable (3). Pressure of injection has not been shown to consistently correlate with intraneural injection. Recently impedance has shown promise as a marker of intraneural placement in an animal study (4). This study was done to study impedance as a marker of intraneural needle placement in human models. Methodology: The first part of the study was done in cadaver dissections and the impedance measurements were done using a 21G Stimuplex needle on the sciatic nerve in the popliteal fossa in 2 cadavers. The measurements were done to assess perineural and intraneural impedance with 2-3 passes on each nerve. It was desired to obtain the impedance values for intraneural and perineural needle placement on fresh nerves. As it is not ethically possible to place a needle intraneurally in living subjects, we decided to take freshly amputated lower extremities and obtain these impedance measurements on the sciatic/tibial nerve within 1 hour of amputation. The impedance values were obtained for perineural placement followed by intraneural placement initially using ultrasound guidance and then by open dissection to expose the nerve. Results: Cadaver study: The initial cadaver values were obtained from 3 sciatic nerves after open dissection. The perineural impedance was 7.6±1.1 kΩ and intraneural impedance was 9.1±1.1 kΩ, an increase of 20%. Amputated limb values: Impedance values have been obtained from 2 amputated limbs thus far. The values obtained are as shown in graph 1. As seen in the graph, the impedance values using ultrasound guidance and open dissection are comparable and there is a 73% increase in impedance values as the needle progresses from the perineural to the intraneural space. [Peri- and intra-neural Impedance values in kΩ ] Conclusion: Our early data shows an increase in impedance as the needle passes from the perineural to intraneural space, therefore adding impedance measurement as a tool while using ultrasound guidance in performing regional anesthesia could help further reduce the incidence of intraneural injections. References: 1. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS, Jamrozik K. Reg Anesth Pain Med. (2009); 34(6): 534-41. 2. Neal JM. Reg Anesth Pain Med. (2010); 35(2 Suppl): S59-67. 3. Sala-Blanch X, López AM, Pomés J, Valls-Sole J, García AI, Hadzic A. Anesthesiology (2011); 115(3): 589-95. 4. Tsui BC, Pillay JJ, Chu KT, Dillane D. Anesthesiology. (2008); 109(3): 479-83 A157 SPINAL CORD STIMULATION EFFICACY: REVIEW OF 7 YEARS' EXPERIENCE FROM AN ACADEMIC CENTER DATABASE L. Tunke, E. Veizi, S. Hayek Case Western Reserve University Medical School-University Hospitals of Cleveland, Cleveland, OH, USA Introduction: Spinal cord stimulation (SCS) is an ever growing field that has been widely applied to treat intractable pain entities since 1967. Accepted indications include postlaminectomy pain, CRPS, peripheral neuropathy, and visceral pain. Several authors have reported case series and few randomized trials (Kemler et al 2005; North et al 2008). Robust analysis in large SCS patient registries is very useful. Purpose: The purpose of this study is to report the 7 year experience of an academic pain medicine practice on the use of SCS for chronic nonmalignant pain. Study design: This is a retrospective single center database review of all SCS trials/implants. Over a 7 year period (2006-2013) in a single academic center 345 patients were subjected to a trial of SCS. 234 patients had a satisfactory outcome (>50% improvement in pain and activity) to justify a permanent implant. Results: Trial/implant ratio in the general population was 67.8% and disease specific was 67.8% for FBSS, 68.2% for CRPS, 83.3% for SFN and 68.4% for PHN/PN and 71.4% for visceral pain post differential nerve block. NRS cores decreased from 8.4 to 3.2 at 1 month and 5.5 at 12 months. The number of back surgeries was not correlated with the satisfaction leading to SCS implant (14% of patient on failed trail group and 15% on successful trial group). Conclusions: SCS can provide significant long term relief in various conditions with chronic intractable pain. Stringent patient selection and rigorous assessment of the pain quality affects the efficacy of this treatment. A158 COMPARISON OF USAGE OF NEUROSTIMULATOR ONLY AND NEUROSTIMULATOR TOGETHER WITH ULTRASONOGRAPHY IN BRACHIAL PLEXUS BLOCK WITH REGARD TO BLOCK SUCCESS, COMPLICATIONS AND PATIENT SATISFACTION E. Keles, A. Turkmen, Z. Ervatan, E. Denizli Anesthesiology and Reanimation, Ministry of Health Okmeydani Training & Education Hospital, Istanbul, Turkey The purpose of this study is to investigate the effects of block success, complications and patient satisfaction of ultrasonography usage in axillary brachial plexus blockage. 50 patients with ASA I-III, over 20 years of age to whom forearm and hand surgery would be performed were included in this study after approval of the ethical committee and informed consent of the patients were obtained. Heart rate, noninvasive blood pressure and peripheral oxygen saturation of the patients were monitored, for whom demographic data were recorded. 2 mg midazolam was administered intravenously half an hour before the application. Brachial plexus blockage was applied in group I (n=25) using neurostimulator only and in Group II (n=25) ultrasonography guided neurostimulator. Procedure time, number of needle insertions, existence of vascular puncture was recorded. Pain felt by the patient during the treatment was recorded by examination with pain scoring. Sensory block developed was controlled with pin-prick test and motor block developed was evaluated with Holmen scale. Operation was started after block formation times were recorded. Need for general anesthesia was recorded. Patients were questioned in the recovery room after the operation if they were pleased with the anesthesia method performed and the answer was recorded. Demographic data, motor and sensorial block onset time, operation and procedure times and pain scores were found to be similar in Group I and II. 2 patients required anesthesia in group I and 3 patients stated that they were unsatisfied, but no statistically significant difference was detected. Number of needle insertions and vascular puncture were significantly lower in Group II. As a conclusion, block success and patient satisfaction in axillary brachial plexus blockage performed using neurostimulator together with ultrasonography were found to be similar and complication rate was found to be significantly lower. A159 THE ANGLE OF NEEDLE INSERTION DURING ULTRASOUND-GUIDED LATERAL SAGITTAL INFRACLAVICULAR BRACHIAL PLEXUS BLOCK 1 2 3 3 V. Uppal , H.K.P. Kalagara , S. McKinlay , A.J.R. Macfarlane , K. Anderson 1 4 2 Department of Anesthesia, London Health Sciences Centre, London, ON, Canada, Anesthesiology 3 Institute, Cleveland Clinic, Cleveland, OH, USA, Department of Anesthesia, Glasgow Royal Infirmary, 4 Glasgow, UK, Department of Anesthesia, Foothills Medical Centre, Calgary, AB, Canada Introduction: Infraclavicular brachial plexus block (IBPB) is particularly useful for elbow, forearm and hand surgery. Whilst real time ultrasound (US) increases the success of this block [1] needle visualization can be difficult [2], despite previously published US and MRI data suggesting a shallow angle of approach [3]. The primary aim of our study was to establish the angle of needle insertion from the anterior chest wall during US guided IBPB in our patients. Our secondary aim was to examine for any correlation between BMI and insertion angle. Methods: Local research ethics committee approval was sought and deemed not necessary for this prospective observational study. A 38 mm linear probe was placed in the parasagittal plane in the deltopectoral groove just medial to coracoid process. The needle was inserted in-plane to the ultrasound beam aiming for the needle tip to be at 6 o'clock position to axillary artery. The angle of needle insertion in relation to the anterior chest wall was measured using Screen Protractor 4.0 (Iconico, 75 East 4th Street, New York). Results: 23 patients were studied, all Scottish-Caucasian. Thirteen patients also received a general anaesthetic as planned. The results are shown in table 1. Values expressed as mean [range], mean (SD) or absolute. Gender (M: F) 13:10 Weight (kg) 82.3 (17.6) Body mass index (kg m-2) 28.5 (5.4) Angle (degree) 50 [33-60] Depth from chest wall to 6 o'clock position (cm) 3.5 [2.1-4.5] Length of needle insertion (cm) 4.8 [3.4-5.8] Needle visibility (Static/Dynamic/Hydrolocation) 9/5/9 'Heeling-in' required? (Yes/No) 9/14 Quality of block (Good/Incomplete/Nil) 22/1/0 Visualization of needle (Easy/Moderate/Difficult) 5/11/7 [Table 1] The Pearson correlation coefficient for BMI and angle of needle insertion was 0.357. The needle insertion angle was significantly greater in BMI>29 compared to BMI< 29 (p=0.0479). ROC (receiver operating curves) analysis suggested that a BMI>35 best predicted difficult needle visualization (Likelihood Ratio 7.5 [95%CI 0.8-182.6]). Discussion: The median angle of needle insertion in relation to chest for our study patients was 50 degree which is much steeper than reported by other researchers [3], possibly due to either anthropological differences between Scottish and Scandinavian patients or a slight difference in the plane of measurement between our work and the previously reported data. Needle visibility was difficult, requiring hydrolocation or 'heeling-in' in 39% of cases. There was a moderate correlation between BMI and angle of insertion. Despite difficulties with needle visualization, the IBPB provided reliable analgesia. References: 1. Dingermans et al. Anesthesthesia Analgesia 2007; 104: 1275-80 2. Macfarlane et al. Continuing Education in Anaeshesia, Critical Care & Pain 2009; 9: 139-143 3. Sauter et al. Anesthesia & Analgesia 2008; 106: 1910-5 Funding disclosure: Only departmental funds were used for this study. No external funds were obtained Personal conflicts of interest disclosure: Nothing to disclose A160 A NOVEL MODIFIED RETROCRURAL APPROACH FOR CELIAC PLEXUS BLOCKADE: THE SINGLE-NEEDLE RETROAORTIC TECHNIQUE S. Volney, M. Kamdar, D. Edwards, A. Thabet, J.P. Rathmell Massachusetts General Hospital, Boston, MA, USA Introduction: Celiac plexus neurolysis is a well-established technique shown to improve upper abdominal cancer-related visceral pain when compared to systemic analgesics alone [1]. While the transcrural celiac plexus approach is the most commonly performed technique, literature suggests that if there is tumor burden in the vicinity of the celiac axis such as in the body or tail of the pancreas, the transcrural approach may be less efficacious [2]. In this instance administration of neurolytic to the retrocrural space targeting the thoracic splanchnic nerves may be more effective. Traditionally the retrocrural approach often requires bilateral needle entry to facilitate neurolytic spread to the splanchnic nerves on both sides of the aorta. In some instances anatomic barriers such as visceral structures and bony abnormalities preclude safe needle trajectory to bilateral retrocrural target sites. We describe a novel, single-needle retroaortic, modified-retrocrural approach for the treatment of intractable upper abdominal malignancy pain in five patients, in whom the traditional transcrural or bilateral retrocrural approaches were not feasible. Methods: Five patients with pancreatic adenocarcinoma and intractable upper abdominal pain presented for celiac plexus neurolysis under CT guidance. The ages of the patients ranged from 57 to 81 years. Anatomic barriers such as deep pleura (Fig. 1) and an enlarged liver (Fig. 2) precluded safe access using a conventional bilateral retrocrural approach. Neurolysis was delivered using a 22gauge Chiba needle initially advanced into the retrocrural space clear of anatomic obstructions and 812 mL of 100% ethanol was injected. Subsequently, the needle was advanced further; posterior to the aorta, into the contralateral retrocrural space and another 8-12 mL 100% ethanol was instilled. Preand 4 week post-intervention pain scores were recorded. Results: All patients had significant pain relief immediately after the procedure. Pre-intervention pain scores ranged from 6-8/10 on an 11-point numerical rating scale (Mean 6.8). Four-week follow up post-intervention pain scores ranged from 0-4/10 (Mean 1.2). There was a mean pain reduction of 5.6/10 (p< 0.005, 95% CI 2.88 to 8.32). Post-intervention contrast demonstrated bilateral retrocrural spread in all cases. There were no significant complications. Discussion: This novel technique represents an effective option when transcrural or traditional bilateral retrocrural routes are not technically practical. The retroaortic approach may be most applicable for patients with excessive tumor burden near the celiac axis and anatomic barriers precluding traditional a bilateral retrocrural approach. Although we demonstrated safe and effective use of this technique in 5 patients, controlled studies will be needed to further elucidate the safety and efficacy of this approach as compared to traditional methods. References: 1. Wong, G.Y., et al., Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA, 2004. 291(9): p. 1092-9. 2. Rykowski, J.J. and M. Hilgier, Efficacy of neurolytic celiac plexus block in varying locations of pancreatic cancer: influence on pain relief. Anesthesiology, 2000. 92(2): p. 347-54. [Figures 1 & 2 Retroaortic retrocrural approach] A161 AN ALGORITHMIC APPROACH TO PLANNING AND PERFORMING CT-GUIDED CELIAC PLEXUS NEUROLYSIS FOR CANCER-RELATED PAIN S. Volney, M. Kamdar, A. Thabet, J.P. Rathmell Massachusetts General Hospital, Boston, MA, USA Introduction: Image-guided celiac plexus neurolysis is an effective therapeutic option in the management of visceral pain related to upper abdominal malignancies [1,2]. With the advancement of multidetector computed tomography (CT), clinicians are turning to CT guided neurolysis as standard of care for percutaneous celiac plexus neurolysis, owing to its clear resolution of anatomic structures which allows optimal pre-procedure planning and intra-procedure visualization. In order to safely and effectively perform CT-guided celiac plexus neurolysis, numerous variables must be considered. For example selection of optimal approach based on tumor location and anatomic barriers, transcrural vs. retrocrural approach, single vs. bilateral needle technique, patient positioning, CT gantry angulation, and neurolytic injectate volume must all be meticulously considered through a clear, methodical approach. Review of the literature demonstrates a lack of a practical, systematic, algorithmic method to planning and performing safe and successful CT-guided celiac plexus neurolysis. Here we propose and evaluate a simple stepwise algorithm to facilitate CT-guided celiac plexus neurolysis. Methods: Eight patients with pancreatic cancer were identified to be candidates for celiac plexus neurolytic blockade under CT guidance. Pancreatic tumor location included 5 patients with pancreatic body/tail disease and 3 with tumor localized to the pancreatic head. Pre-procedure planning and CT guided neurolysis was performed using a proposed systematic algorithm based on celiac plexus targets, pancreatic tumor location, and anatomic barriers (Fig. 1). Pre- and 4-week post-intervention pain scores were recorded. Results: Celiac plexus neurolysis was safely and effectively performed on all patients. Preintervention scores ranged from 4-10/10 on an 11-point numerical rating scale (mean 7.38). Fourweek follow up pain scores ranged from 0-7/10 (mean 2.13). There was a mean pain reduction of (5.25) (p< 0.002, 95% CI 2.91 to 7.66). Post-intervention contrast demonstrated adequate bilateral neurolytic spread in all cases. There were no significant procedural complications. Discussion: With consideration of the numerous variables involved in planning and performing a successful CT-guided celiac plexus neurolysis, we have developed a practical and stepwise procedural algorithm for clinicians. While further data needs to be gathered on a larger number of patients, this algorithm appears to be both safe and effective. This algorithm may be most applicable to clinicians who are relatively new to performing CT-guided celiac plexus neurolysis for pancreatic cancer pain. References: 1. Wong, G.Y., et al., Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA, 2004. 291(9): p. 1092-9. 2. Eisenberg, E., D.B. Carr, and T.C. Chalmers, Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg, 1995. 80(2): p. 290-5. [Figure 1 Celiac plexus neurolysis algorithm] A162 ASSOCIATIONS OF PSYCHOSOCIAL AND DEMOGRAPHIC FACTORS WITH ACUTE PAIN FOLLOWING TOTAL KNEE ARTHROPLASTY 1 1 1 1 2 1 1 C.M. Greco , K.L. Vulakovich , D. Landsittel , I. Belfer , F. Dai , L. Crossett , J. Chelly 1 2 3 4 Psychiatry, Anesthesiology, University of Pittsburgh, Pittsburgh, PA, Yale University, New Haven, CT, USA Introduction: Psychosocial factors such as anxiety, depression, and catastrophizing about pain have been implicated as contributors to the pain experience. The purpose of this study was to evaluate associations between psychosocial and demographic variables and acute pain post-total knee arthroplasty (TKA). Materials and methods: After completing informed consent at a baseline visit, 153 Caucasian adults scheduled for unilateral TKA surgery at the University of Pittsburgh Medical Center underwent clinical evaluation and completed self-report psychosocial questionnaires: Anxiety, Depression, and Sleep disturbance were assessed using the NIH roadmap initiatives' Patient Reported Outcomes ® Measurement Information System (PROMIS ) static forms (www.nihpromis.org), the Perceived Stress Scale, the Somatization scale from the Brief Symptom Inventory-18, the Pain Catastrophizing Scale, and the Neuroticism scale from the Big 5 Personality Inventory. Pain was assessed via patientreported numeric rating scale (NRS) (0-10) of pain with movement and pain with pressure during clinical examination at the pre-surgery baseline visit and on day 2 post-surgery. Data analyses included robust linear regression analyses to evaluate simple and multivariable associations between demographic and psychosocial variables and level of pain on day 2 post-surgery. Any single variable found to be associated with pain at p< 0.10 level of significance was included in multivariable models, which were considered significant at p< 0.05. Results: The average age of participants was 64 years (SD=8.8) and ranged from 40 - 88. The majority of participants were female (58%). Forty-six percent had a household income of < 60K per year. At the baseline visit, the majority of participants rated their pain with movement and with pressure as “none/mild.” On day 2 post-surgery, 74 (48.5%) reported moderate/severe pain (defined as NRS >3) with movement and 20 (13%) reported pain with pressure as moderate/severe. In simple robust linear models to predict day-2 pain with movement (adjusted for baseline pain), lower income was marginally associated with pain with movement (p= 0.077). For the outcome variable pain with pressure, gender (p< 0.001), Somatization (p=0.10), and the Hopelessness subscale of the Pain Catastrophizing Scale (p=0.05) were significant in simple robust linear models adjusted for baseline pain. These three variables were included in the multivariable model for pain with pressure along with baseline pain. The overall model was significant at p< 0.001, and gender remained significantly associated with pressure pain (t=-5.37, p< 0.001). Coefficient P value [95% Conf. Interval] Baseline pain with pressure 0.19 0.141 -.0640215 .4465779 Female gender -2.09 <0.001 -2.855827 -1.316902 Somatization -0.66 0.138 -1.542587 .2161941 Hopelessness -0.002 0.974 -.1036909 .1003167 [Pain with Pressure on post surgery day 2] Discussion: We found that a large proportion of TKA patients experience moderate to severe pain post-operatively. Female gender was significantly associated with having less pain with pressure postTKA when controlling for baseline pain, hopelessness, and somatization. In contrast to a recent study of TKA patients, psychological factors such as depression were not associated with acute pain postsurgery. Funding disclosure: NIH/NIDCR (0408-CT2048) PI Dr. Jacques Chelly. No Conflicts of Interest to Disclose. A163 CAN ULTRASOUND GUIDANCE REDUCE THE VOLUME AND CONCENTRATION OF LOCAL ANESTHETICS FOR SUCCESSFUL INTERSCALENE BRACHIAL PLEXUS BLOCK? A SYSTEMATIC REVIEW J.J. Wang, C. Margarido, M. Tavakkolizadeh, C.J.L. McCartney Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Introduction: Reducing the dose of local anesthetic (LA) required for interscalene brachial plexus 1 block (ISBPB) improves its safety by decreasing the risks of systemic toxicity and block side effects 2,3 4,5,6 such as phrenic nerve palsy. Since ultrasound-guidance increases block efficacy, it has been used to investigate the effects of reduced LA dose on block success, duration and incidence of 2-14 phrenic nerve palsy. We aim to summarize the effect of low-dose ultrasound-guided ISBPB on block efficacy. Methods: Medline, Medline in-process, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched to retrieve randomized controlled trials (RCTs) and prospective observational trials studying ultrasound-guided ISBPB for shoulder surgery using less than established LA volumes (20ml for analgesia and 40ml for anesthesia). Outcome measures included block success, duration and incidence of phrenic nerve palsy. Methodological 15 quality was determined using the Thomas Quality Assessment Tool for observational trials and the 16 Cochrane Collaboration's Tool for RCTs . Results: The electronic databases identified 199 abstracts, of which 61 were duplicates, and 37 did not meet inclusion criteria. 13 of the 24 full articles reviewed met criteria, representing 614 patients. A moderate dose-response correlation(Figure1) between block success and log dose, volume and concentration was established through weighted linear regression. The predicted effective dose(ED) 95(95%CI) for successful ultrasound-guided ISPBP with ropivacaine was 106mg(23-148) for dose, 18ml(4-24) for volume at 0.5%, 15ml(2-22) for volume at 0.75%, and 0.56%(0.24-0.72) for concentration at 20ml. Block duration did not correlate with LA dose(Figure2) or volume. Phrenic nerve palsy showed a moderate-high dose-response correlation with LA dose and volume. The predicted ED95(95%CI) for normal diaphragmatic function was 20mg(16-51) for ropivacaine dose and 3.5ml(2.7-7.4) for ropivacaine volume at 0.75%. Discussion: Ultrasound-guidance can reduce LA dose for ISBPB while maintaining block efficacy, although block success can be compromised by very low LA doses(< 40mg). The conservation of block duration at doses which reduce block success suggest that once LA is accurately deposited, even very low volumes can maintain shoulder analgesia. The wide confidence intervals reflect small sample sizes (15-40 patients per allocation), as well as heterogeneity between trials regarding block technique (single or multiple injections; single-shot or catheter), operator experience (single or multiple), and surgery subtypes (open or arthroscopic). Therefore, future RCTs studying the effect of LA dose on ISBPB efficacy are still necessary. [Figure 1: Block success vs. ropivacaine dose] [Figure 2: Block duration and ropivacaine dose] References: 1. Minerva Anesthesiol. 2010;76:1088-1090 2. Reg Anesth Pain Med. 2009;34:498-502 3. Can J Anaesth. 2011;58:1001-1006 4. Br J Anaesth. 2011;106:124-130 5. Anaesth Intensive Care. 2005;33:719-725 6. Br J Anaesth. 2012;108:1006-1010 7. Br J Anaesth. 2008;101:549-556 8. Reg Anesth Pain Med. 2010;35:529-534 9. Anesth Analg. 2011;113:951-1005 10. Shanghai Med J. 2009;32:34-36 11. Reg Anesth Pain Med. 2011;36:17-20 12. Reg Anesth Pain Med. 2012;37:495-501 13. Anaesthesiology. 2010; 112:374-1381 14. Br J Anaesth. 2012;Nov 29 15. Worldviews Evid Based Nurs. 2004;1(3):176-184 16. BMJ. 2011;18:343 Funding: Department of Anesthesia, Sunnybrook Health Sciences Centre Personal conflicts of interest disclosure: Nothing to disclose A164 THE EFFECT OF EPINEPHRINE USE ON ULTRASOUND GUIDED UPPER EXTREMITY BLOCKS: A META-ANALYSIS C.G. Samuelson, O. Willett, S. Arulkumar, V. Koyyalamudi Anesthesiology, Louisiana State University, Shreveport Health System, Shreveport, LA, USA Introduction: The use of ultrasound is quickly becoming the gold standard for regional anesthesia(1). Studies show that upper-extremity blocks are associated with an increased incidence of nerve injury(2). Currently, equipoise exists regarding the need/safety of epinephrine in upper-extremity blocks(3). The goal of this study was: 1. To review the current literature on the use of epinephrine in ultrasound-guided blocks of the upper extremity. 2. To use meta-analysis to compare the effectiveness and complication rate of studies using epinephrine (EPI+), to those not (EPI-) Material and methods: A literature search was conducted on the use of ultrasound-guided blocks of the upper extremity using PubMed, Ovid and Cochrane databases. Inclusion criteria stipulated only prospective/randomized studies of adult patients undergoing ultra-sound guided upper extremity block for surgery be included; that the studies note whether epinephrine was used; and that the studies report on the incidence of block failure, vascular puncture, new-onset paresthesia, and use of supplemental anesthesia. Random-effects meta-analysis was used to compute effect sizes and compare EPI+/- studies. Analysis of bias was completed for all study outcomes. Results: 12 EPI+(990 patients) and 7 EPI-(645 patients) studies were included for analysis. No studies directly comparing EPI+/EPI- were found. Random-effects meta-analysis revealed an incidence of block failure of 5%(3.4-7.3) and 3.6%(1.9-6.5) in the EPI+/- studies respectively. While the incidence of vascular puncture was ~2% among all studies; “comparing” the studies yielded a 4.2%(3.9-4.5,p< 0.001) increase in paresthesia and an 8.5%(8.3-8.7,p< 0.001) increased need for supplemental anesthesia among the EPI+ studies. Overall, there appeared to be significant publication bias (p< 0.001), with underreporting of failure rate (14 “file-drawer” publications), supplementation of anesthesia (8 “file-drawer” publications), vascular puncture (9 “file-drawer” publications) and paresthesia (6 “file-drawer” publications). Discussion: Currently, debate exists over the use of epinephrine in peripheral nerve blocks. While no studies exist directly comparing EPI+/-, the use of epinephrine appears to be associated with a significantly increased need for anesthetic supplementation. This is counterintuitive, as epinephrine should extend the duration of neural blockade. The relationship between this and the increase in paresthesia needs further exploration. While only higher level-of-evidence studies were included, we detected significant publication bias. Therefore, our meta-analysis is hindered both by a lack of studies directly comparing EPI+ to EPI-, and accurate reporting on the efficacy and complications of ultrasound-guided upper extremity blocks. As such, further study is warranted. Funding: None References: 1. Ultrasound in regional anaesthesia. Griffin, J and Nicholls, B. 65, s.l. : Anaesthesia, 2010. 2. Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry. Sites, B D, et al. 5, s.l. : Reg Anesth Pain Med, 2012, Vol. 37. 3. Effects of epinephrine in local anesthetics onthe central and peripheral nervous systems: Neurotoxicity and neural blood flow. Neal, Joseph M. s.l. : Regional Anesthesia and Pain Medicine, 2003, Vol. 28, pp. 124-34. A165 THE MISSING (VIRTUAL) LINK IN REGIONAL ANESTHESIA EDUCATION J.B. Winchester, G.V. Hickman, E. DeBusk, S.E. Thomas 1 2 3 Regional Anesthesia Fellowship, The Andrews Institute ASC, BLOCKJOCKS Research and Education Foundation, The Andrews Institute ASC, Gulf Breeze, FL, USA Introduction: Over the last decade we have seen an increased utilization of regional anesthesia techniques. Despite the clear evidence supporting the benefits of regional anesthesia to patients and facilities, physicians often hesitate to adopt these techniques, citing their lack of comfort with their skill level and lack of guidance in learning new techniques. There are one to two day courses available which attempt to teach these skills but doctors return home with little follow up support and difficulty remembering what they practiced on a dummy for a couple hours on a Saturday afternoon. Our technology advancement called the Docstream Doc-In-The-Box (DITB) bridges the gap for physicians looking to expand their skills and learn regional anesthesia without having to leave home. Materials and Methods: DITB is a portable video system designed by Brandon Winchester and engineered by Clark-Powell. DITB allows a novice user to easily record and live broadcast ultrasoundguided regional anesthesia procedures (demonstration video: http://www.blockjocks.com/tLq32). The system has several key features. There are two different video cameras: one for a big picture shot and the second for a close up shot of the hands. A third video input is an ultrasound. The video signal can be switched on the fly between the two cameras and ultrasound using an iPad app, and also features a virtual laser pointer which allows structures to be pointed out during the procedure. High definition video is recorded onto an SD card, and can be live broadcast or videoconferenced onto the web using a variety of PC software options, including Skype & GoToMeeting. DITB also features a case which allows it to ship from facility to facility. Results: At the Andrews Institute ASC, we are using DITB to record and broadcast videos of regional anesthesia procedures every week, making them available to physicians around the world on BLOCKJOCKS.COM. We now have >4,000 monthly video views from over 100 countries. Discussions: DITB offers physicians the opportunity to observe blocks without having to leave their institution, and also gives universities & industry the opportunity to further assist physician and nurse education by remote proctoring procedures with our deployable system. Regional anesthesia programs are being started and expanded upon directly thanks in part to the education afforded by DITB technology and www.blockjocks.com. Our vision is that DITB play a critical role, not only in the expansion of regional anesthesia procedures, but medical procedures of all kinds. Furthermore, studies should be performed in order to validate the DITB-driven improvements in physician skills and nerve block utilization that we have observed anecdotally in communications with our “virtual preceptors” from around the world. This abstract is exempt from IRB approval. References: http://journals.lww.com/rapm/Abstract/2010/03001/The_American_Society_of_Regional_Anesthesia_ and.11.aspx http://www.modernhealthcare.com/article/20120109/MAGAZINE/301099939 http://www.newtek.com/index.php?option=com_content&view=article&id=554 http://www.avnetwork.com/av-technology/0002/is-there-a-doctor-in-the-cloud/90242 www.blockjocks.com Personal Conflict of Interest: Winchester- BBraun Medical, Kimberly Clark, Pacira, Sonosite, DOCSTREAM INC, Blockjocks.com LLC. Hickman- BBraun Medical, Kimberly Clark, Pacira Debusk- BBraun Medical A166 ECONOMIC BURDEN OF UNEXPECTED DAYS OFF INCURRED BY PATIENTS AND THEIR CAREGIVERS FOLLOWING OUTPATIENT SURGERY S.M. Owens, A. Manohar, K. Cheung, T. Stierer, C. Wu Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA Introduction: The economic burden of unexpected days off incurred by patients and their caregivers following outpatient surgery has not been fully examined. As part of a prospective survey study to assess the impact of outpatient surgery on recovery of patients and their caregivers in the postoperative period it was noted that a percentage of respondents required additional, unanticipated time off from work. Extrapolating that data to the total number of outpatient surgery visits we were able to calculate the economic burden of those additional days. Methods: Surveys assessing postoperative recovery were given to patients at six time points: on postoperative days 0-3, 7 and 30. Surveys assessing the burden of informal caregiving were given to each patient's primary caregiver at four time points, on postoperative days 1-3 and 7. As part of the survey patients and caregivers were asked if they needed to take any additional days off from work than originally scheduled. The data gained from those respondents was then used to assess the cost of additional days off using both the federal minimum wage and a figure used in the GallupHealthways Well Being Index to calculate the economic cost of absenteeism. Results: Forty-four adult patients undergoing outpatient surgical procedures and their primary caregiver were enrolled. We found that 10% of patients needed to take more time off from work than originally anticipated. Pain was the most frequently cited symptom to prevent the patient from resuming normal activities. 0.05% of caregivers also needed to take more time off from work than originally anticipated. Using the minimum wage to calculate the cost of a single 8 hour day of work or a derived figure used by Gallop representing the cost of a typical employee absentee day and multiplying that cost by the the number of outpatient procedures performed annually, the cost of these additional days off was calculated to be between ~$300 million and ~$1.77 billion. Conclusions: The economic burden of additional time off for patients and their caregivers may top $1.5 billion. The primary reason cited for that additional time is pain. Currently the cost of medical care is being very closely scrutinized, and anesthesiologists as acute pain specialists in the perioperative period are uniquely positioned to reduce the very significant economic burden our findings unveil. A167 POSTOPERATIVE PAIN AND ANALGESIA REQUIREMENTS FOLLOWING ARTHROSCOPIC HIP SURGERY: A RETROSPECTIVE CHART REVIEW E. Yap, M. Behrends, P. Aleshi Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA Introduction: Arthroscopic hip surgery is becoming increasingly popular to diagnose and treat interior joint pathology. These surgeries are commonly done in the outpatient setting with many patients being discharged the day of surgery. However, in spite of the minimally invasive nature of these procedures, some patients appear to suffer a considerable amount of pain. Subsequently, timely discharge of these patients can become challenging due to the need for more aggressive acute pain therapy and for the management of analgesia related side effects such as sedation and nausea. The purpose of this hypothesis generating retrospective chart review is to assess the acute outcome of patients undergoing arthroscopic hip surgery, and to identify subgroups of patients at risk to experience increased pain requiring more aggressive treatment. Patients at high risk for increased postoperative pain may benefit from pre- or intraoperatively performed regional anesthesia techniques to reduce postoperative pain, postoperative analgesia requirements, and decrease the length of stay in the post-anesthesia care unit (PACU). Such preemptive anesthetic and analgesic management of selected patients undergoing arthroscopic hip surgery could help improve patient satisfaction and facilitate early discharge. Material and methods: Review of the surgical and anesthetic records of 100 patients that underwent arthroscopic hip surgery at a University outpatient orthopedic center from June 2010 through April 2012 was conducted. Demographics, duration of surgery and PACU stay, intraoperative opiate administration, post-operative visual analog scale (VAS) pain scores, postoperative analgesia requirements, and postoperative nausea and vomiting (PONV) were reviewed. Opioid doses were converted into their morphine equivalents to allow comparison. Results: Average surgery time was 59±22 minutes. Intra-operative opiate administration averaged 16±7 mg morphine equivalents. In the PACU the highest recorded VAS pain score was on average 5.9±2.5, resulting in mean post-operative opiate requirements of 14±10 mg morphine equivalents. PONV was treated in 10 patients. Average duration of PACU stay was 124±48 minutes. Linear regression analysis demonstrated that higher VAS pain scores in the PACU were associated with longer surgery duration (p = 0.103) and an osteotomy performed during surgery (p = 0.033). There was no correlation between age, sex, or intraoperative opioid administration and postoperative VAS pain scores. Patients with higher VAS pain scores in the PACU had highly significant increased PACU opiate requirements (p < 0.0001) and longer PACU stays (p = 0.0008). Discussion: Patients undergoing arthroscopic hip surgery may expect these minimally invasive procedures to elicit minimal pain. However, the present chart review demonstrates that these surgeries may result in a significant amount of postoperative discomfort leading to increased postoperative analgesia requirements and subsequently prolonged PACU stays. The use of regional anesthesia in patients undergoing arthroscopic hip surgery is not well established; however, regional anesthesia techniques could be advantageous for these patients, especially in cases of longer duration and cases including an osteotomy. Reference: YaDeau JT, Tedore T, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesthesia and Analgesia 2012; 115(4):968-72 Funding disclosure: Nothing to disclose. Personal conflicts of interest disclosure: Nothing to disclose. A168 PHENTOLAMINE HASTENS RECOVERY OF SENSATION AFTER NERVE BLOCK IN RODENTS M. Young, S. Wang, J. Mao Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA Introduction: Prolonged regional block can be associated with complications such as delay of transfer of care and patient dissatisfaction. Dental literature has demonstrated that phentolamine reduces the duration of soft-tissue numbness. We hypothesized that phentolamine would pharmacologically hasten reversal of peripheral regional anesthesia. Materials and methods: We examined the effect of phentolamine on recovery of sensation after sciatic nerve block in a rodent model. IRB approval for use of these animals was obtained. We utilized hte radiant heat light beam of a plantar analgesia meter and observed time to foot withdrawal. Five rats were placed in raised, transparent enclosures, and the heat light beam was focused on the plantar hind paw in an area innervated by the sciatic nerve. We measured the time to hind paw withdrawal up to a maximum of twenty seconds. This test was then performed on the opposite hind paw and repeated again on both limbs. The reaction latencies obtained formed the baseline reaction times. The rats were then lightly anesthetized with 1% enflurane to facilitate landmark-based sciatic nerve block. On the first experimental day, injections were delivered to the right limb. For each rat, the limb was infiltrated in the area of the sciatic nerve with 0.1mL of 2% lidocaine with epinephrine. Subsequent reaction latencies were collected. The rats were then re-anesthetized and given either 0.1mL of 0.9% saline (control group) or 100mcg/0.1mL phentolamine (experimental group) at the previously injected area. Reaction latencies were again recorded at 60 and 120 minutes. This protocol was repeated five days later with injections to the left limb providing five control and five experimental datasets. Results: At each timepoint , we found the mean reaction latency for each limb and then the difference in the means between the injected and uninjected limb for both control and experimental groups. The difference in mean reaction latencies were similar between groups at three of four timepoints: small at baseline and 120-minute timepoints and increased at the 15 minute timepoint. At 60 minutes, the difference between limbs was decreased in the phentolamine group yet remained increased in the saline group (P < 0.05). Discussion: The data indicate that phentolamine can speed the recovery of sensation to heat stimulus after sciatic nerve block with lidocaine and epinephrine in rats. In the saline group, withdrawal latency difference was sustained 45 minutes after nerve block (60 minute timepoint) but already resolved in the phentolamine group. We postulate that phentolamine´s alpha-receptor blockade property may promote clearance of local anesthetic. The clinical effect might be more pronounced after local anesthesia complemented with epinephrine. We believe this is the first study to show that a pharmacologic agent can hasten recovery from peripheral nerve blockade. Previous reports have shown that duration of neuraxial blockade can be shortened with crystaolloid epidural washout and intrathecal lavage. In dental literature, phentolamine reduces the duration of soft-tissue numbness. In conclusion, phentolamine hastens the return of sensory function following sciatic nerve block with lidocaine and epinephrine in rats. A169 REDUCTION OF ISOLATED HIP DISLOCATIN WITH KETAMINE 1 2 3 4 5 5 F. Akyildiz , H. Turgut , S. Ozyurek , O. Ersen , S. Ekinci , S. Bilgic 1 2 Orthopaedics, Malatya Military Hospital, Malatya, Orthopaedics, Siirt Military Hospial, Siirt, 4 Orthopaedics, Aksaz Military Hospital, Mugla, Orthopaedics, Maresal Cakmak Military Hospital, 5 Erzurum, Orthopaedics, Gulhane Military Medical Academy, Ankara, Turkey 3 Introduction: Traumatic hip dislocatons are orthopaedic emergecies occured after high energy traumas and can accompanied by fractures of pelvis, acetabulum, femoral head, patella or femoral, obturatuar nerve lesions and posterior cruciate ligament ruptures. Traumatic hip dislocations should be reducted as soon as posibble. Case report: A 26 years old male admitted to our emergency department with the complaint of left hip pain, limitation of range of motion and limping after tractor accident. His left hip was in adduction, flexion and internal rotation and there were no other systemic findings. Neurovascularexamination was normal. Initial radiological evaluation was made with AP pelvic graphy and dislocation without fracture found and for early reduction no advance radiological test was done. 40 mg. Ketamine (0.6 mg./kg) IV administered and after 2 minutes reduction manuever longitudinal traction, internal rotation and adduction force with flxed knee was applied and reduction was achieved in 30 seconds. After reduction position of extremity in hip extansion and external rotation was secured and controlled by AP pelvis x-ray and computed tomography. After reduction no fractures or neurovascular deficit was seen. After first week sitting in bed and isometric exercises, in second week mobilization without weightbearing allowed. On 8th week full weight-bearing allowed. At follow up visit on the 12th month of injury full range of motion of hip was found and avascular necrosis of femoral head did not observed on control MRI. Discussion: After traumatic hip dislocations vital functions must evaluated first. Because it is %95 related with other systemic injuries. Isolated hip dislocation without fracture is rare (1). Reduction must be done as soon as possible to avoid avascular nerosis of femoral head.for low complication rate some authors suggests reduction in 12 hours (2), while some suggests reduction in 6 hours (3). Closed reduction of hip fracture-dslocations are contraindicated. In this case isolated hip dislocation reducted using potent analgesic effectof ketamine. References: 1.Gogus A, Akpinar S, Unal M, Sonmez B, Hamzaoglu A. Kalça kırıklı çıkığı (pipkin tip-IV) ile beraber görülen travmatik aort kapak rüptürü Ulus Travma Acil Cerrahi Derg 2001 (7):1; 66-69 2. Herman C. Epslein: "Posterior Iracture-dislocalion of the hip" J. Bone and Joint Surg. Vo . 56-A, No 6, 1974. 3. Dreinhöfer KE, Schwarzkopf SR, Haas NP, Tscherne H. Isolated traumatic dislocation of the hip. Long-term results in 50 patients. J Bone Joint Surg [Br] 1994;76:6-12. A170 PERIPHERAL NERVE FIELD STIMULATION TO TREAT POST-HERNIORRHAPHY PAIN SYNDROME R. Alsaigh, G. Novak Department of Anesthesiology & Pain Medicine, St. Elizabeth's Medical Center. Tufts University, Boston, MA, USA Introduction: Post-herniorrhaphy pain syndrome is not uncommon. Fifteen -30% of patients will develop pain post hernia repair. We present a patient with persistent left inguinal pain following an open left inguinal hernia repair for 7 months. Case report: A 44 year old male patient status-post left inguinal hernia repair in April 2012, complicated by persistent post-surgical pain. Patient described his pain as 8/10 on VAS, sharp, with pins and needles over the incision and occasionally radiating down the left scrotal area. His pain was severe enough to interrupt his sleep during night. Patient was referred to us after he failed conservative management. He had wound infiltration with local anesthetic, provided him with one day relief. Followed by left sided TAP block which gave him one and a half weeks of pain relief. A discussion was made with the patient about peripheral nerve field stimulation, and he agreed to it. After obtaining clearance from the psychology service we proceeded with the trial. In our pain clinic, we brought the patient to the procedure room, placed him in supine position; his left inguinal area was prepped and draped with standard sterile technique. Using a 14 G Tuohey epidural needle the electrical lead was placed in the subcutaneous tissue just below the scar. It was connected to the pulse generator and tested.The patient felt tingling over his usual pain site. Our patient had a five day trial. He reported (tremendous) improvement in his pain 75 -80 %. His pain score decreased to 3/10. In November 2012, our patient underwent permanent placement of peripheral nerve field stimulation implant. Discussion: Post- herniorrhaphy pain syndrome is a common problem, Fifteen -30% following elective inguinal hernia repair. In most of the cases the cause is unknown. Management usually starts with conservative medical treatment (NSAID, anticonvulsant, antidepressant), Surgery (scar revision, release of nerve entrapment), interventional nerve blocks (TAP block), and Physical therapy (TENS unit). For patients who fail these measures, either spinal cord stimulation or peripheral nerve field stimulation can be effective and offering these patients a trial should be considered. [Intraoperative PNS implant] [PNFS Leads and pulse genetrator ] References: 1) post-operative Inguinodynia from hernia surgery By Jeffrey B. Mazin, MD, FACS. Practical pain management, April 2010 2) Genitofemoral and Ilioinguinal neuralgia after laparascopic versus open inguinal herniorrhaphy Narouze, S.N.1; Zakhary, E.2; Basali, A.1 2002 Fall A28 3) Classifying post-herniorrhaphy pain syndromes following elective inguinal hernia repair. Loos MJ, Roumen RM, Scheltinga MR. Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands. [email protected] 4) Neuromodulation. 2012 Jun 1. doi: 10.1111/j.1525-1403.2012.00463.x. Combined Spinal Cord and Peripheral Nerve Field Stimulation for Persistent Post-Herniorrhaphy Pain. Lepski G, Vahedi P, Tatagiba MS, Morgalla M. Department of Neurosurgery, Eberhard Karls University, Tübingen, Germany. 5) Neuromodulation. 2000 Aug;3(3):155-7. doi: 10.1046/j.1525-1403.2000.00155.x. Spinal cord stimulation for post-herniorrhaphy pain. Elias M. The Pain Clinic, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Patient is aware, and agrees for the case report publication. A171 REGIONAL BLOCKADE FOR TOTAL SHOULDER REPLACEMENT IN A PATIENT WITH SEVERE LUNG PATHOLOGY, OBSTRUCTIVE SLEEP APNEA, AND CARCINOID SYNDROME E. Baker, N.C.K. Lam, M. Charles, C. Arndt, T.R. Petersen Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM, USA A 73 y/o woman was scheduled for total shoulder arthroplasty. Her past medical history was significant for obesity, severe mixed obstructive and restrictive lung disease requiring home oxygen, biochemically active metastatic rectal carcinoid syndrome, peripheral neuropathy of the lower extremities, and severe degenerative osteoarthritis of the left shoulder with severely restricted motion. The patient had also been on multiple medications for chronic arthritic and neuropathic pain. There was concern that managing the patient's pain with a regional block placed at the interscalene level could compromise the patient's lung function and result in respiratory distress even with volumes as 1 low as 5 ml. There was also concern that avoiding regional anesthesia altogether and controlling her pain using systemic medications only could also pose a problem given her chronic opioid use and her obstructive sleep apnea. The anesthesia team decided that the best approach would be a regional anesthesia technique that could be used for intraoperative and postoperative pain control but could reliably avoid involvement of the phrenic nerve. Using a 80 mm 22 G echogenic stimulating needle with ultrasound guidance, the posterior cord of the brachial plexus was identified by visualization and confirmed by stimulation resulting in deltoid muscle 2 movement using a transverse infraclavicular approach. 8 ml of 0.5% ropivacaine with dexamethasone was injected into the area around the posterior cord and good spread around the posterior cord was noted. After this injection was completed the patient was placed in a seated position, and a suprascapular nerve block was placed under ultrasound guidance at the level of the 3 spine of the scapula using 12 ml of 0.5% ropivacaine with dexamethasone. [SUPRASCAPULAR NERVE BLOCK] The patient was again placed supine, and immediately said that she had no pain in her shoulder for the first time in many years. Pulmonary ultrasound did not demonstrate paralysis of hemidiaphragm. She proceeded to the operating room and was placed under general anesthesia for her comfort. An arterial line was placed given the patient's history of carcinoid. The patient tolerated the procedure well with no reaction to incision and no exacerbation of her carcinoid symptoms. The patient was extubated uneventfully at the end of the operation and had good pain control. The local anesthetic provided pain relief for approximately 18 hours and she was able to be transitioned onto oral agents without difficulty. The patient was discharged from the hospital on POD #2 with no complications. Follow up has been uneventful. 1. Riazi S, et al. Effect of local anesthetic volume (20 mL vs 5 mL) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008;101:549556 2. Nicholas Lam, et al. Transverse infraclavicular approach to the brachial plexus - MEAC. ASRA 2012; Abstract 109 3. Harmon D, et al. Ultrasound-guided suprascapular nerve block technique. Pain Physician. 2007;10(6):743-746. A172 ANESTHETIC MANAGEMENT USING REGIONAL ANESTHESIA IN A PATIENT WITH TYPE 1 VON WILLEBRAND DISEASE UNDERGOING OPEN SHOULDER SURGERY G. Geng-Ramos, E. Shepard, V. Bansal Anesthesiology, University of Maryland, Baltimore, MD, USA A 21 year old male with congenital Type I von Willebrand Disease was scheduled to undergo a repeat left shoulder Latarjet Procedure. The patient was diagnosed with von Willebrand Disease as a young child, with baseline laboratory studies of von Willebrand antigen of 11% (NR: 60-150%), coagulation factor VIII 17% (NR: 50-150%), ristocetin cofactor activity of 10% (NR: 70-132%), and normal vWF mulitmers, with poor response to DDAVP. The patient's surgical history involved a previous Laterjet procedure performed under general anesthesia. His post-operative course was notable for inadequate pain control, poor physical therapy compliance and the need for further surgeries. Anesthetic plan for this procedure was general anesthesia combined with a continuous Interscalene catheter for post-operative pain management. One hour prior to the procedure, the patient received Humate-P 50units/kg (3,650 units of ristocetin cofactor activity). An interscalene catheter was placed under ultrasound guidance preoperatively without complication. General anesthesia was induced, and surgery begun. Intraoperatively the patient was noted to have an increased amount of generalized bleeding. The patient received an additional dose of 3,650 units of Humate-P, with significant improvement of intraporative bleeding . The remainder of the surgical intervention was uneventful, and transfusion of blood products was not required. Total surgical time was 182 minutes, EBL 600 ml. Postoperatively, the patient received repeat does of Humate-P at 12 hours and 24 hours postoperatively, as advised by his hematologist. He described good pain control with an continuous interscalene catheter infusion of ropivicaine and a back-up PCA. He began rehabilitation therapy on post-op day 1 with adequate pain control (Pre-therapy pain score 0/10, post-therapy pain score 4/10). The patient was discharged home with his interscalene catheter and an ambulatory pain pump containing 0.2% ropivacaine. The catheter was removed at home without complications. Although bleeding diathesis is a relative contraindication to regional anesthesia, with appropriate perioperative management of our patient's coagulopathy, we believed the benefits of interscalene catheter for our patient outweighed the risks. Despite having to redose Humate-P, proper placement using ultrasound guidance and meticulous securing of the catheter ensured a successful postoperative coarse in our patient. A173 MULTIMODAL APPROACH FOR MANAGING ACUTE POST-TRAUMATIC PAIN IN A HEROIN ADDICT G.F. Barbosa-Hernandez, V. Masri, J. Eismon, B. Astley, M. Bassett Anesthesia, MetroHealth Medical Center, Cleveland, OH, USA Introduction: Patients with pain refractory to opioid use that require surgery present a challenge. Refractory cases prompt the use of NMDA receptor antagonists and off-label use of medications with analgesic side effects. Case: A 25yoM was brought to the ED after a motor vehicle accident. Injuries included bilateral open ankle fractures, left tibia fracture, and a right shoulder fracture/dislocation. He was neurovascularly intact. Laboratory workup was normal, except for the toxicology screen which was positive for recent opioid and alcohol use. The pt admitted to drinking 6-8 beers daily and abusing heroin (1 gram daily) for the past 5 years. His right shoulder was reduced, and he then went to the OR for emergent bilateral ankle ORIF and external fixator placement to his left tibial plateau fracture. Following a rapid sequence induction, his anesthesia was maintained with isoflurane, remifentanil infusion, and multiple boluses of fentanyl and hydromorphone. He had an uneventful PACU recovery and was admitted to a regular floor. Later that day, the acute pain service was consulted due to uncontrolled pain (10/10) and agitation. We intiated IV lorazepam via CIWA protocol, started a ketamine infusion (5mg/hr), increased his IV PCA hydromorphone to 1mg every 6 minutes (demand only), began pregabalin (50mg orally TID), and began memantine (5mg orally BID). The following day the patient's pain was 7/10. We increased pregabalin (100mg orally TID), began methadone (10mg orally QID) and dronabinol (2.5mg orally BID), and later in the evening discontinued ketamine. On POD 2, the patient's pain had improved significantly (2/10). On POD 3, we stopped dronabinol and PCA hydromorphone and started oral hydromorphone (4mg q3h PRN). Following discontinuation of the IV hydromorphone, the patient's pain worsened. Over several days, we increased his methadone dose (15mg orally TID and 30mg at nighttime). On POD 6, he was discharged with his pain controlled to an acute rehabilitation facility. A week later, he underwent definitive fixation of his left tibia plateau fracture. He was compliant with his regimen at the rehab facility and there were no issues in managing his pain following surgery. Conclusions: Opioid tolerant patients have hyperalgesia and require aggressive treatment perioperatively. Methadone's activity at adrenergic receptors provides analgesic effects not influenced by opioid tolerance. NMDA receptor antagonism by methadone blocks morphine tolerance and opioid induced hyperalgesia. Ketamine's NMDA receptor antagonism can block the development of opioid tolerance and opioid-induced hyperalgesia and reverse both phenomena. Complementary use of other NMDA receptor antagonists, like memantine, has been suggested to decrease opioid tolerance in patients with opioid resistant pain[1]. Dronabinol has been advocated in the setting of chronic opioid therapy for chronic non-cancer pain, as an adjuvant, with some encouraging results related to satisfaction with therapy; however, no opioid sparing properties have been found[2]. References: 1. Grande, L.A., Ultra-low dose ketamine and memantine treatment for pain in an opioid-tolerant oncology patient. Anesth Analg, 2008. 107(4): p. 1380-3. 2. Narang, S., Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy. J Pain, 2008. 9(3): p. 254-64. A174 SUCCESSFUL MANAGEMENT OF INTRACTABLE BRACHIAL PLEXOPATHY PAIN WITH CONTINUOUS LOCAL ANESTHETIC INFUSION VIA AN IMPLANTED INTERSCALENE CATHETER TUNNELED TO A PERCUTANEOUS ACCESS PORT D.B. Boyce, K.V. Vlassakov, P.L. Pelletier, S. Narang Anesthesiology, Perioperative and Pain Medicine, The Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA 1 Introduction: Pain from neoplastic plexopathy can be challenging to treat . We report successful management of intractable brachial plexopathy pain with continuous local anesthetic infusion via an implanted interscalene catheter connected to a percutaneous access port, placed under ultrasound guidance. Case: A 35 year-old woman presented with severe upper extremity neuropathic pain caused by a metastatic synovial sarcoma invading her right brachial plexus. Extensive treatment since diagnosis 9 years prior included multiple surgical resections, radiotherapy, and chemotherapy. The apical tumor had been resected through a median sternotomy, removing the right first rib and medial clavicle. Subsequent paravertebral and epidural spread, required cervical laminectomies and hardware fusions, precluding epidural analgesic techniques. At presentation, the pain was severe and uncontrolled with high-dose analgesic therapy, including IV hydromorphone over 215 mg/day, IV ketamine 0.2 mg/kg/hour, gabapentin 900 mg PO TID, lidocaine 5% patch/day, rendering the patient into a semi-conscious state. Examination revealed right lower neck and upper chest deformity by tumor and scarring. A temporary interscalene brachial plexus catheter was placed under ultrasound guidance after a 22 mL ropivacaine 0.5% bolus, followed by bupivacaine 0.125% infusion (Fig.1). [Figure 1] Within 10 minutes, profound analgesia ensued and a technically challenging ultrasound-guided periarterial injection (80 mg methylprednisolone, 8 mL 0.5% ropivacaine) was performed empirically at the brachial plexus cords for possible extended analgesia. As the pain decreased and the analgesics weaned, she became more alert and ambulatory. Six days later, a permanent interscalene catheter was placed under ultrasound guidance via anterior approach, tunneled subcutaneously and attached to an implanted Port-a-Cath™ for long-term infusion (Fig.2). [Figure 2] Pain and analgesic requirement continued to decrease. Functional status, quality of life, and therapeutic options improved - she went home with a portable infusion carrying case, managed by visiting nurses, and was able to resume chemotherapy. She remained on a stable dose for six weeks without tachyphylaxis. During a neutropenic episode, a dehiscence and leak at the Port-a-Cath™ incision site required removal of the system. An intrathecal pump was then implanted. Conclusions: Neuropathic pain originating from complex compressive and infiltrative neoplastic plexopathy may be treated effectively by continuous local anesthetic plexus infusion via an implanted catheter with an access port. This technique is reversible and preferable to destructive procedures such as cordotomy. It may also increase therapeutic options not otherwise tolerable, such as plexus steroid injections or chemotherapy. Discussion: There have been surprisingly few reports of successful treatment of malignant neuropathic pain with continuous peripheral nerve blocks since 1994 when the first case of 2 continuous interscalene analgesia for a patient with Pancoast tumor was published . Curiously, both then, and in our case, peripheral nerve blockade was considered only after neuraxial modalities were excluded - an interesting, yet persistent preference, possibly based on medical culture, pain stereotypes and predominant practice. References: 1. Kori et al. Brachial plexus lesions in patients with cancer. Neurology 1981;31:45-50 2. Sato et al. Continuous Interscalene Block for Cancer Pain. Regional Anesthesia 1994;19(1):73-74 A175 DISCOVERY OF DVT DURING PLACEMENT OF FEMORAL NERVE CATHETER FOR TOTAL KNEE ARTHROPLASTY E.R. Briggs Vanderbilt University Medical Center, Nashville, TN, USA Introduction: Practitioners of regional anesthesia may often find themselves in pressured situations to get procedures done quickly. It is very easy to develop tunnel vision and not observe surrounding anatomy as critically as we should. I would like to present an instance where being observant of surrounding anatomy positively affected a patient´s care. The patient was a 39 year old female with rheumatoid arthritis and history of deep venous thrombosis (DVT) secondary to Antiphospholipid Antibody Syndrome with a rare, acquired prothrombin antibody. She was scheduled for revision of a right total knee arthroplasty (TKA), following infection of her previous replacement. The anesthetic plan included preoperative femoral nerve catheter and sciatic nerve block. A general anesthetic was planned per the patient's request. Ultrasound was utilized for femoral nerve block/catheter placement. During the procedure, it was noted that the common femoral vein was somewhat resistant to compression. Further evaluation of the vein using color doppler revealed flow in only a small portion of the vessel, consistent with possible thrombus. This patient's hypercoagulable state, immobility of the affected limb, and conversion of Coumadin to low molecular weight heparin (LMWH) preceding surgery, placed her at very high risk for development of DVT. The procedure was aborted and, following discussion with the surgeon, surgery was postponed pending a formal venous ultrasound study. The study revealed subocclusive thrombus in the common femoral vein but extensive occlusive thrombus in the femoral, popliteal, and calf veins. Surgery was cancelled and the patient was scheduled for immediate follow up with her hematologist. The patient's LMWH dose was increased to 100mg BID. Six weeks later, a follow up venous doppler examination revealed recanalization of the occlusive thrombus. The patient then underwent an uneventful general anesthetic for TKA revision that included a femoral nerve catheter and sciatic nerve block. Discussion: This incidental finding from using ultrasound to perform regional anesthesia, had a positive and significant effect on the management of this patient. Without evidence of the DVT seen while placing the femoral nerve catheter, this patient would have gone to the OR for TKA and could have very likely suffered a significant embolic event leading to significant morbidity or mortality. Examination of the literature reveals multiple descriptions of non-neural pathology noted during ultrasound guided nerve blocks. At least two reports exist describing a DVT found while performing 1,2 ultrasound guided femoral nerve blocks. There are likely other similar instances that have gone either unreported or unnoticed. If the anesthesiologist performing or observing the procedure is rushed or focuses solely on the neural anatomy, these clinically significant findings are simply missed. Sites, et al ask, as practitioners of ultrasound regional anesthesia, should we be expected or required 2 to investigate surrounding and relevant structures. I propose we remain observant and avoid tunnel vision. References: 1. Sutin KM, et al. Deep venous thrombosis revealed during ultrasound-guided femoral nerve block. Br J Anaesth 2005;94:247-8. 2. Sites BD, et al. On the edge of the ultrasound screen: regional anesthesiologists diagnosing nonneural pathology. Reg Anesth Pain Med 2006;31:555-62 A176 UNEXPECTED DIFFICULT PAIN CONTROL FOLLOWING BILATERAL HAND DE-GLOVING SPLIT-THICKNESS SKIN GRAFT SURGERY M. Charles, M. Billstrand Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM, USA Introduction: A 32-year old male presented to our Outpatient Surgery Center for split-thickness skingrafting (STSG) and revision for bilateral hand de-gloving injuries he had sustained during a workrelated incident several months before. His wounds included right first and second digit amputations, incomplete amputations of the remaining fingers of the right hand and left hand de-gloving injury requiring a groin flap. The patient was otherwise healthy with his only prior surgery being his previous finger amputations and groin flap. On the day of his revision/STSG surgery, the patient was evaluated and an anesthetic plan including a pre-operative supraclavicular nerve block for the left hand and general anesthesia was formulated. The right side did not need a nerve block as it was insensate. Surgery was uncomplicated and the patient arrived in the PACU extubated and responsive. Shortly after arrival, the patient started to experience “10/10” pain in his left groin, the site of the skin graft harvest, not relieved by repeated doses of IV morphine and fentanyl administered by the PACU nurse. Upon evaluation by the staff anesthesiologist, it was determined that an ultrasound guided ilioinguinal/iliohypogastric nerve block would be performed. The nerves were identified and 15ml of 0.5% ropivicaine was injected in the plane between the transversus abdominis muscle and the internal oblique muscle. Within 5 minutes, the patient's pain was significantly decreased and he was discharged home later that afternoon. Discussion: As this case illustrates, the actual injury site being grafted does not necessarily constitute the most painful area after split-thickness skin grafting has been performed. In fact, the “donor site” (area from which the graft is taken) will many times be much more prone to post-operative pain. This can pose a challenge to the anesthesiologist in planning for pain control, especially if a regional technique is being utilized. One method that we have found to be effective is pre-operative peripheral nerve block for the area to be harvested with subsequent delineation of the area that has been anesthetized. This requires close communication with the surgeon to establish the planned harvest site, coordination in order to perform to the nerve block ahead of time in the pre-operative area, and time enough for the nerve block to establish itself so borders can be demarcated. Alternatively, as occurred in this case, a post-operative “rescue” nerve block can be performed in the PACU if IV or oral analgesics are not covering the pain. This method, while initially faster (i.e. does not require additional pre-operative time to perform and confirm adequacy of the nerve block) has the drawback of subjecting the patient to undue discomfort. Rescue blocks have the additional disadvantage of oftentimes being performed under non-ideal circumstances, that is, on patients who have difficulty maintaining a position due to pain or target sites that are partially or completely covered by post-operative dressings or appliances. A177 CASE OF A “STUCK” EPIDURAL CATHETER IN THE LATERAL RECESS S. Cheng, T. Halazynski, M. Jacoby Yale Anesthesiology, Yale University School of Medicine, New Haven, CT, USA Epidural analgesia performed for labor management has a good safety profile. However, complications may include inability to remove catheter following delivery, usually due to knot formation or coiling. 20yo female G2P0010, 36+5wks, 5'3”, 72.6kg, without lumbar spine pathology, in active labor, requested epidural for analgesia. Catheter placement occurred uneventfully: patient sitting, standard ASA monitors, skin sterilely prepped and draped. Loss of resistance occurred at 6cm, catheter threaded, and secured at 9cm to skin. Test dose negative and patient reported pain relief within 10min of dosing. 60min later patient reported increased pain with no relief despite local boluses. Decision made to repeat epidural, but catheter removal was met with resistance. Removal with patient sitting, arched back, flexed waist, arc of shoulders right then left while traction was applied proved ineffective. Saline injection also failed. Catheter marking at the skin was now 6cm (Figure1). Patient continued to labor and second epidural was placed in vertebral space above initial catheter without complication. Both catheters were secured and taped to patient's skin. Following delivery, second epidural catheter was easily removed. Trapped catheter was still unable to remove despite repeated attempts using methods described above. Neurosurgery consulted and CT scan showed catheter tip terminating in right L1-L2 lateral recess with acute turn of 75 degrees after traversing the L1-L2 spinous processes (Figure2). With patient in right lateral decubitus position, flexion/extending of the waist, arching of pelvis left and right, and saline injection permitted catheter removal with tip intact. 1 Various maneuvers/positioning have been described to assist in removal of trapped catheters. Suggestions include: 1) avoid multiple attempts of extraction in same position; 2) cease traction with evidence of excessive catheter stretch; 3) discontinue if catheter begins to stretch; reattempt several hours later; 4) flexion/extension can be combined with lateral decubitus patient positioning; 5) removal 2-5 in extreme flexion/extension; 6) CT scan to identify etiology; and 7) injection of sterile saline. Case is notable for aberrant location of where catheter was trapped and atypical patient position of noninvasive technique for successful catheter removal. Figure 1: Top catheter removed from patient. Bottom catheter for comparison (~7cm stretch). Figure 2: CTscan of epidural catheter migrating into the right facet joint. [Figure 1] [Figure 2] References: 1. Kendall M, Nader A, Maniker R, McCarthy R. Removal of a knotted stimulating femoral nerve catheter using a saline bolus injection. Local Reg Anesth. 2010;3:31-4. 2. Mitra R, Fleischmann K. Management of the sheared epidural catheter: is surgical extraction really necessary? J Clin Anesth. 2007; 19:310-4. 3. Lala P, Langer V, Rai A, Singh R. A rare complication of epidural anesthesia a case report with brief review of literature. Indian J Anaesth. 2011;55:629-30. 4. Renehan E, Peterson R, Penning J, Rosaeg O, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth. 2000;47:329-33. 5. Chang P, Hu J, Lin Y, Tsou M. Butterfly-like knotting of a lumber epidural catheter. Acta Anaesthesiol Taiwan. 2010;48:45-8. A178 THE ROLE OF LONG TERM OUTPATIENT CONTINUOUS PERIPHERAL NERVE CATHETERS IN THE TREATMENT OF NON-HEALING WOUNDS T. Pontinen, C. Chiang, W. Ennis, A. Rakic 1 2 Anesthesiology, Vascular Surgery, University of Illinois, Chicago, IL, USA Introduction: Non-healing wounds and the pain associated with them can be difficult to manage. Traditionally, medications have been the mainstay of treatment, but continuous peripheral nerve catheters (CPNCs) are proving to be an effective alternative. For the last two years, we have treated multiple patients suffering from a variety of non-healing wounds successfully using CPNCs and here we present three cases exemplifying this success. Material and Methods/Results: The first case is a 52 year old female with diabetes mellitus and peripheral vascular disease and a seven year history of non-healing foot ulcers. For 6.5 years, her pain was treated unsuccessfully with high dose opioids, limiting her visit compliance, and ability to function independently. In 5/2011, we placed an infra-gluteal sciatic CPNC with continuous infusion (2 mL/hr 0.2% ropivicaine) and patient controlled boluses (10 mL every 90 min), maintaining it from 5/2011 - 1/2012. During her weekly debridement visits, her catheter was bolused with 2% Lidocaine, providing surgical analgesia in a clinical setting. Over these eight months, her compliance with wound care visits, independence, and quality of life vastly improved, and her ulcers healed completely. The second case involves a healthy 43 year old man who developed a large wound on his left medial knee after falling from his bike. A distal femoral CPNC was placed initially for post operative pain control following an incision and debridement/wound VAC placement, but was kept in over the following 4.5 months of rehab, dressing changes, and skin grafts. His catheter was maintained in the same manner as the first case. Throughout this time, he never required any narcotics and his wound completely healed. The final case involves an 81 year old man with metastatic prostate cancer and chronic venous insufficiency who suffered from poorly treated lower extremity chronic wounds for over a year. An infra-gluteal sciatic CPNC was placed and over the following two months, his narcotic requirements decreased and ulcers shrank. Although he elected to remove his catheter after a superficial wound infection before his ulcers completely healed, his current quality of life and narcotic requirements are much better than prior to the placement. Discussion: CPNCs provide highly effective analgesia and facilitate patient compliance while avoiding the problems associated with opioid use. In addition to pain control, CPNCs have the theoretical benefits of increased tissue perfusion and oxygenation through sympathectomy induced vasodilation (1), antiinflammatory effects (2), and may attenuate resulting pain sequelae, including phantom limb syndrome (if an amputation is required) (3). Given the favorable risk / benefit of regional anesthetic techniques, its theoretical advantages, its ease of use in the outpatient setting, and our ever-growing population of patients with non-healing wounds, we not only advocate further research in this promising field, but also the increased use of these catheters in clinical practice. References: 1. Bhattarai BK, Rahman TR, et al. J Nepal Med Assoc. 2006 Jul-Sep;45(163):295-9. 2. Swanton BJ, Shorten GD. Int Anesthesiol Clin. 2003 Winter;41(1):1-19. 3. Battista B, D´Addabbo M, et al. Anesthesia and Analgesia. 2010 November 111 (5) A179 REGIONAL ANESTHESIA FOR A PATIENT WITH SEVERE PULMONARY DISEASE D. Chirumamilla, O. Viktorsdottir, K. Fikry, K. Fleischmann Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Introduction: We describe the anesthetic management of a 60-year-old female with complex medical history and significant pulmonary comorbidity requiring urgent surgical debridement of an infected elbow S/P total elbow arthroplasty. History: The patient is a 60-year-old female who presented to our institution with an infected right elbow prothesis requiring urgent surgical debridement. She had a history of severe COPD (FEV1 22%)requiring 2-3L home O2 and multiple episodes of hypercarbic respiratory failure requiring prolonged intubation and a previous tracheostomy, which was later reversed. In 2009 she required intubation for iatrogenic pneumothorax after nerve block. The patient had a history of ischemic cardiomyopathy, multifocal atrial tachycardia, recent atrial fibrillation with a rapid ventricular response, anxiety, hepatitis B and C infection, chronic alcohol dependence and substance abuse. After an extensive evaluation, we decided that avoiding general anesthesia and any significant sedation would be optimal, given her history of prolonged intubations and mechanical ventilation after general anesthetics and her history of substance abuse. Plan and procedure: The decision was made to proceed with regional anesthesia using an axillary block as the primary anesthetic for the procedure. We felt that this would be the best and safest option for our patient in order to avoid risks associated with more proximal brachial plexus blocks, that is risks of pneumothorax and hemidiaphragmatic paralysis that would have been detrimental for this patient. After applying standard ASA monitors the patient was positioned for axillary block placement. Under sterile conditions, we used an ultrasound probe to visualize the axillary artery and the cords of the brachial plexus in cross section. Using ultrasonic guidance a 22 gauge 50mm insulated panjunk needle was advanced until the cords of the brachial plexus were approximated and a total of 18ml of 1.5% mepivicaine and 8 ml of 0.5% bupivicaine with 1:400000 epinephrine was injected in 5 ml aliquots incrementally with no resistance after negative aspiration. The patient experienced no paresthesias and tolerated the procedure well without complications. Surgical anesthesia was achieved in 5 minutes with the patient requiring no supplemental anesthesia or sedation intraoperatively. Discussion: By performing an axillary block under ultrasound guidance we were successful in providing a safe and satisfying anesthetic for this patient with high peri-operative risk of pulmonary morbidity and mortality. By avoiding general anesthesia and keeping our patient spontaneously breathing intraoperatively we minimized the risk of hypercarbic respiratory failure and prolonged postoperative hospital stay. By administrating long acting local anesthetic we achieved good postoperative analgesia and reduced postoperative opioid requirement in this medically challenging patient. References: · Sanchez M, Malhotra N, Lin L., Semin Cardiothorac Vasc Anesth. 2012 Mar;16(1):59-64., End-stage pulmonary disease and brachial plexus regional anesthesia: their implications on perioperative pulmonary function. · Urmey WF, Gloeggler PJ., Reg Anesth. 1993 Jul-Aug;18(4):244-9., Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume. A180 DISCREPANCY OF SUBSEQUENT BLOCK SUCCESS RATE IN A PATIENT WITH ADHESIVE CAPSULITIS L. Curia, J. Kent Anesthesiology/ Pain Management, University of Rochester Medical Center, Rochester, NY, USA Adhesive Capsulitis of the glenohumeral joint can be either primary or secondary to an underlying condition like diabetes, Thyroid illness and Trauma.Mean age of onset is 55 in males and 52 in females. The incidence is higher in depression, anxiety, migraine headaches, hypertension, diabetes and chronic back pain. In secondary capsulitis the adhesions are in the joint with no involvement of the capsule resulting in a non-functional frozen joint. In the primary form, there is fibroblastic proliferation of the capsule so the shoulder freezes is in a functional position. There is gradual and painful restriction of the motion so treatment modalities are directed to improving this.We present a case of adhesive capsulitis in a patient with injury to the ipsilateral elbow who came for a series of interscalene blocks for temporary analgesia before aggressive PT. 49 year-old male with a work-related injury to his left elbow with ruptured biceps tendon. He underwent repair of this and required further manipulation under anesthesia. He had resultant compressive ulnar neuropathy at the elbow as well as carpal tunnel syndrome and a claw-type deformity. He required further elbow lysis of adhesions for which he had an infraclavicular block that failed and was repeated in the supraclavicular approach with good results.He then developed left frozen shoulder and scapular winging. He participated in physical therapy with poor outcomes given his underlying pain. We were contacted by the surgical team to possibly use nerve blocks to facilitate PT and improve his ROM.We performed an unsuccessful ultrasound-guided interscalene block with a 22G 2-inch long needle via an in-plane view. 20cc of 0.125% Bupivacaine were injected We proceeded to do another left interscalene nerve block without pain relief or motor/sensory changes either.He had further visits and a second practitioner performed the blocks. The second time was successful with duration over 24 hours using 30ml of 0.25% bupivacaine. The third block was successful but there was ulnar sparing. The fourth time there was a new block failure and it had to be repeated with success. Regardless of the type of capsulitis, there is a gradual restriction of the ROM of the joint with resultant pain. The treatment goal is pain reduction with preservation of shoulder mobility. PT is one of the main pillars of these therapies and needs concomitant adequate analgesia to be achievedMultiple cases have been described about the usefulness of regional anesthesia in assisting with exercise tolerability. The idea is to provide sensory block with the least motor inhibition. The use of ultrasound in regional anesthesia has grown significantly over the past few decades and it allows us to target our injection sites as well as to observe for local anesthetic spread. It was our experience in this case that the spread patterns would change from one block to another and so would the effectiveness and duration of the block. We believe the brachial plexus, just like the glenohumeral joint, might have microscopic collagen deposits that could explain the difficult and erratic access to the sheath. A181 THREATING CHRONIC SHOULDER PAIN WITH ULTRASOUND-GUIDED PULSED RADIOFREQUENCY LESIONING OF THE SUPRASCAPULAR NERVE: CASE REPORTS 1 2 1 S. Deniz , S. Bilgic , T. Purtuloglu , A. Atim 1 1 2 Anesthesiology, GMMA Haydarpasa Training Hospital, Ankara, Orthopedics, GMMA Haydarpasa 3 4 Training Hospital, Istanbul, Gulhane Military Medical Academy, Anesthesiology, GMMA, Ankara, Turkey İntroduction: Threating chronic shoulder pain with pulsed mode radiofrequency (PRF) lesioning attractive as a non- destructive method is favored. We present a method for PRF using ultrasound guidance in patients with chronic shoulder pain in this reports. Case reports: Two males and a female patients with 86,63 and 70-year-old had chronic shoulder pain. Diagnostic suprascapular block was performed with the method described by Wertheim and Rovenstine. We got approval from patient with pain relief in 1-3 days for PRF threapy. 5 cm SMK needle with 4 mm active tip was inserted postero- anterior direction using an out-of-plane or in-plane. The suprascapular artery was first identified with color Doppler imaging. Suprascapular nerve was seen near the suprascapular artery. Location of suprascapular nerve was corrected by sensory and motor stimulation. PRF lesioning was carried out once for 300 seconds. After the procedure patient's pain score was reduced from 8,7,8 out of 10, to 3,1,2 out of 10 in a visual analog scale (VAS). All patients were satisfied with treatment and their shoulder movements improved. Conclusion-results: PRF treatment using ultrasound guidance can reduce the risks of harming not only suprascapular nerve but also surrounding vascular structure. Also ultrasound helps the operator manipulate and advance the needle to a more precise position. A182 LIPOSOMAL BUPIVICAINE FOR ANALGESIA FOLLOWING MULTIPLE RIB FRACTURES: A CASE REPORT E. Draper, B.A. Pearce-Smith, J.E. Chelly Division of Acute Interventional Perioperative Pain, UPMC - Presbyterian Shadyside Hospital, Pittsburgh, PA, USA Introduction: Regional anesthesia has been demonstrated to provide optimum pain management in the patient with multiple rib fractures, because it preserves respiratory function, avoids tracheal intubation, and decreases the occurrence of pneumonia. This case report examines the role that liposomal bupivacaine may play. Materials and methods: The Acute Interventional Perioperative Pain Service (AIPPS) was consulted regarding an 86 year old male, status post motor vehicle accident with multiple injuries including acute fractures of 8 right ribs and 6 left ribs. At the time of consultation the patient was post admission day 11, on a therapeutic heparin infusion for the treatment of a recent pulmonary embolism, and ventilator dependent with a tracheostomy. He had failed spontaneous breathing trials (SBT) on the ventilator due to rib fracture induced chest pain. Following patient assessment, and discussion with the trauma team, single shot injections at multiple paravertebral levels with liposomal bupivicaine was proposed to minimize the risk of bleeding associated by the combination of thrombolytic therapy and peripheral nerve block. The blocks were performed after the heparin infusion was stopped for 4 hours. The 20 mL vial of 1.3% liposomal bupivicaine suspension (266 mg) was diluted with preservative-free normal sterile saline to 30 mL and used for the bilateral multiple single shot paravertebral nerve blocks, performed under ultrasound guidance in the left lateral decubitus position. Results: The next morning the patient had improved dramatically, denying chest pain via written communication for the first time. He ultimately succumbed to deconditioning after 7 hours of SBT, and was returned to controlled ventilation. The following day the same scenario occurred. Since there was a concern for CHF, it was decided not to repeat the blocks. Eventually the patient was successfully weaned to a trach mask, and discharged to an outside care facility. Discussion: This case illustrates the relative complexity of patients with multiple rib fractures and therefore the relative value of prolonged single shot blocks to preserve respiratory function. Our standard protocol for the management of pain following multiple rib fractures utilizes continuous paravertebral blocks. Following the performance of these continuous blocks patients receive thromboprophylaxis. In this case, where this patient received ongoing therapeutic anticoagulation, single shot blocks with a long lasting local anesthetic preparation were performed. Further research with liposomal bupivicaine is required to determine the relative clinical indication of this preparation in trauma patients. References: Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple rib fractured ribs: a focus on regional techniques. Current Opinion in Critical Care 2011, 17:323-327. Mohta M, Verma P, Saxena A, et al. 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. A183 A CASE OF ACUTE TAKOTSUBOS CARDIOMYOPATHY ASSOCIATED WITH SPINAL BLOCK T. Egan Department of Anaesthesiology, Saint Michaels Hospital, Toronto, ON, Canada Tackotsubos Cardiomyopathy is defined as a disease exhibiting acute left ventricular apical ballooning of unknown cause. The left ventricle takes on the shape of a “takosubo” (Japanese octopus trap). In the majority of patients there is resolution of the apical akinesis within a month. A dynamic obstruction of the left ventricular outflow tract is also observed(1) I would like to report the case of a 90 year old female scheduled for a right total hip replacement for osteoarthritis. She had a past history of hypertension, dyslipidaemia, rectal cancer, DVT, and rheumatic fever. Preoperative echocardiogram had demonstrated no significant valvular involvement and normal LV and RV. ECG demonstrated sinus rhythm with LVH by voltage criteria. Her medications included Metoprolol, Enalapril and Warfarin. She was to be bridged with LMWH ECG , NIBP, pulse oximetry, 20 guage IV cannula and spinal anaesthetic were established (2.5ml of 0.5% isobaric bupivacaine, 25 guage Whitacre needle). Blood pressure fell from 130/70 to 80/40 with ECG demonstrating no untoward changes. 50 micrograms of phenylephrine was administered with BP coming up to 110/60. The patient was transferred from the block room to the OR. . The patient was conversant and happy during this time. ECG monitoring was re-established prior to transfer onto the OR table and ST elevation was noted in lead II and III. NIPB was 120/40 and block to ice was T6 bilaterally. The patient was completely comfortable and demonstrated no symptoms of heart failure. A 12 lead ECG demonstrated 2mm ST elevation in V3, V4 and V5 consistent with an anterolateral myocardial infarction. Cardiology attended the OR, Heparin 4000IU intravenously, aspirin 160mg PO plus clopidogrel 300mg PO were given. Coronary angiogram demonstrated no culprit lesion. Left ventricular angiography was performed which demonstrated akinesia of the anterolateral,apical and inferoapical segments (grade 3 left ventricle). The basal segment was contracting normally. Echocardiogram demonstrated an ejection fraction of 43% with systolic anterior wall motion. Five days later, prior to discharge, there was restoration of function with ejection fraction up to 73%.Incidentally there were no signs of spinal haematoma. The underlying etiology of takotsubos is thought to be based on an exaggerated sympathetic stimulation (2). This patient denied any feeling of anxiety and her outward appearance was consistent with this. This presentation is unusual in that this patient had no symptoms of chest pain or dyspnea, or evidence of emotional or physical stress. Left ventricular ejection fraction is reported to resolve within a mean time of 7-37 days (2) and in this patient it had resolved by day five. One must conclude the haemodynamic stress of the spinal block must have had some role in the dynamic presentation of this stress cardiomyopathy. References: 1.Kawai, Sachio, Akira Kitabatake, and Hitonobu Tomoike. "Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy." Circulation journal: official journal of the Japanese Circulation Society 71.6 (2007): 990. 2.Pilgrim, Thomas M., and Thomas R. Wyss. "Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review." International journal of cardiology 124.3 (2008): 283-292. A184 SEIZURE POST BRACHIAL PLEXUS BLOCK IN PATIENT WITH REMOTE HISTORY OF SEIZURES WITH NON TOXIC DOSE OF LOCAL ANAESTHETIC T. Egan Department of Anesthesiology, Saint Michaels Hospital, Toronto, ON, Canada I would like to report a case of local anaesthetic toxicity in a patient with a pre-existing convulsive disorder with a non toxic dose of local anaesthetic. There has been a previous case report of a patient receiving brachial plexus block with dosing within recommended limits who developed neurological symptoms of local anaesthetic toxicity with a childhood history of febrile convulsions (1). There have also been 4 case reports of LA toxicity encountered with patients with pre-exisitng neurological conditions, particularly cerebral palsy (2). A 38 year old female weighing 62 KG presented for a right thumb metacarpal fusion. She had a past medical history of rheumatoid arthirits, temperomandibular sugery and a remote history of simple partial seizures. She requested a regional technique. Supraclavicular block was undertaken using ultrasound and nerve stimulation. The patient was premedicated with 2 MG of midazolam. Triceps stimulation was observed at 0.5mA and an adequate spread of LA was observed on ultrasound in what appeared to be normal anatomy. A total dose of Ropivicaine 100mg plus Lidocaine 200mg was injected in a fractioned injection with regular aspiration and no suggestion of a intravascular injection. This dose did not exceed recommended maximal local anaesthetic dose for her weight (3) Approximately one minute post injection the patient had a tonic clonic seizure. Resuscitation as per ASRA guidelines was initiated with 100ml intralipid 20% administered followed by 0.25mg/kg per hour infusion, Simultaneously the patient was intubated and sedated with midazolam. No heamodynamic instability was observed, the patient awoke around 30 minutes later, seizures had terminated and patient was orientated and uneventfully extubated. She was reviewed by a staff neurologist and discharged the same day. This case poses the question that in the absence of a precipitating cause such as intravascular injection or toxic doses of Local anaesthetic did this patient history of seizures predispose to neurotoxicity of local anaesthetic. The ASRA guidelines on Local Anaesthetic toxicity emphasise the primacy of preventing LAST as the most effective intervention and advise dose reduction in those with IHD, cardiac conduction abnormalities and those at the extremes of ages, but not those with a history of seizures, although heightened awareness of LAST is recommended in those with neurological disorders (4) 1. Satsumae, T., et al. "Convulsions after ropivacaine 300 mg for brachial plexus block." British journal of anaesthesia 101.6 (2008): 860-862. 2. Di Gregorio, Guido, et al. "Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009." Regional anesthesia and pain medicine 35.2 (2010): 181 3. Miller, Ronald D., Lars I. Eriksson, and Lee A. Fleisher. "Miller's anesthesia". 4. Neal, Joseph M., et al. "ASRA practice advisory on local anesthetic systemic toxicity." Regional anesthesia and pain medicine 35.2 (2010): 152. A185 SURAL NERVE PAIN: SIMILAR RESPONSE BETWEEN PULSED RF AND METHYLENE BLUE CHEMONEUROLYSIS S. EL Ahdab, B. Mitchell, M. Eckmann Anesthesiology/Pain, UTHSCSA, San Antonio, TX, USA Background: Radiofrequency Neurolysis ( RF and pulsed RF) and chemoneurolysis ( methylene blue and dextrose) have been used successfully in treating a multitude of several chronic pathologies especially for nociceptive and neuropathic pain. Pulsed RF has been recommended more for peripheral nerve pain as it has less risk of deafferentation potential. Objectives: To report on similarity in pain relief from Pulsed RF vs methylene blue chemoneurolysis. Methods: The case described here is that of a 46 year old female who fractured her right fifth toe and since then had been having pain along the right sural nerve distribution. She had multiple successful sural nerves blocks with a 1:1 solution of 2% lidocaine and 0.5 % Marcaine. The patient then underwent a methylene blue chemoneurolysis. This was followed 5 months later with pulsed Radiofrequency ablation. Results: The patient reported complete relief for 2 weeks from both methylene blue as well as Pulsed RF. She was back to her baseline pain score 6 weeks after both procedures. Limitations: This report describes a single case report. 1 Conclusions: A previous case report has showed successful pain relief from sural nerve pulsed RF. Our case follows showing no clear difference in efficiency between sural nerve pulsed radiofrequency vs sural nerve methylene blue chemoneurolysis. 1-Pulsed radiofrequency of the sural nerve for the treatment of chronic ankle pain. Pain Physician. 2011 May-Jun;14(3):301-4. Todorov L. A186 LUMBAR SYMPATHETIC BLOCK SUCCESSFULLY TREATS CHEMOTHERAPY INDUCED BILATERAL LOWER EXTREMITY NEUROPATHIC PAIN IN A PATIENT WITH MULTIPLE MYELOMA M.F. Esposito, M. Anitescu Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA Chemotherapy-induced peripheral neuropathy is a major side effect of many chemotherapeutic 1 agents. CIPN can be extremely painful and disabling, causing significant functional debility and 2 decreasing quality of life. It is not entirely clear how chemotherapeutic agents cause neuropathic pain yet with increasing numbers of patients experiencing excellent outcomes and prolonged survival due 3 to chemotherapy, long-term pain management is becoming a challenging aspect of treatment. We present a 57-year-old female with multiple myeloma who developed BLE pain after chemotherapy whose pain was improved with lumbar sympathetic blocks. A 57-year-old female with MM developed severe BLE CIPN (burning, tingling numbness, 10/10 pain) after effective lenalidomide and Bortezomib treatment. Increasing doses of opioids (methadone 120mg daily, hydromorphone, hydrocodone), gabapentin, and amitriptyline were ineffective: she continued to have severe pain, poor sleep architecture, poor appetite, an inability to work, and drastically decreased physical activity secondary to pain. Physical exam demonstrated diminished sensation over the dorsal and plantar aspects of the feet. The patient underwent caudal epidural steroid injection with minimal pain relief. The patient returned for fluoroscopy-guided bilateral LSB at the level of L3. Each block consisted of 40mg triamcinolone, 5mL 0.5% bupivacaine, and 5mL 2% lidocaine. The patient experienced profound pain relief (pain score2/10). The patient returned two weeks later for repeat LSB with similar success. The relief lasted for two months until chemotherapy was restarted at which point her pain worsened. She again underwent bilateral LSB with excellent analgesia. Furthermore, the patient's opioid requirements were drastically reduced to methadone 30mg daily and occasional acetaminophen with codeine. Although it is not completely understood how chemotherapeutic agents result in chronic pain, it has been demonstrated that these agents cause structural damage to peripheral nerves that result in 1,2 aberrant somatosensory processing of the peripheral and central nervous systems. Both 3 lenalidomide and Bortezomib have been implicated. The exact mechanism underlying the peripheral 3 neuropathy is unknown. Cells of the peripheral nervous system are vulnerable as primary sensory and autonomic neurons are contained in ganglia that lie outside the blood-brain barrier and are supplied by fenestrated wall capillaries allowing free passage of molecules between the circulation and the ECF in the ganglia. Neuropathic pain is often multifactorial and the SNS may play a role in the 4 maintenance of certain neuropathic pain states. The underlying mechanism for sympathetically mediated pain is unclear; however, it has been suggested that the presence of an abnormal coupling 5 between the sympathetic and the somatosensory nervous system may be responsible for SMP. This coupling may be in the peripheral nerve or the DRG due to neurogenic inflammation following nerve 5 lesion. Sympathetic blocks targeting SMP to treat neuropathic pain syndromes (e.g., CRPS, PHN) 6 have been described. However, our unique case utilized LSB as part of a regimen to treat CIPN. It is possible that LSB for CIPN are able to reduce the SMP component at the DRG and interrupt the cycle of uncontrolled pain, allowing the appropriate healing process to commence. 1. WolfS.EuroJCancer2008;44:1507-1515. 2. WindebankAJ.CurrentOpinioninNeurology1999;12(5):565-71. 3. WindebankAJ.JPeriphNervSys2008;13:27-46. 4. TranKM.AnesthAnalg2000;90:1396-1401. 5. Krumova.RegAnesthPainMed2011;36(6): 560-7. 6. DayM.PainPract2008;8: 98-109. A187 ELBOW SURGERY PERFORMED UNDER SUPRACLAVICULAR BLOCK ON A PATIENT WITH HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES (HNPP) J. Galey, E. Shepard 1 2 Anesthesiology, University of Maryland School of Medicine, Anesthesiology, Kernan Orthopaedics and Rehabilitation, Baltimore, MD, USA Presentation: Our patient was a 25yo M with a history of Hereditary Neuropathy with Liability to Pressure Palsies (HNPP), a rare genetic neuromuscular disorder that renders a patient easily susceptible to nerve injury from pressure, stretch, or repetitive use. The patient fell from a roof at work and sustained a Terrible Triad Injury to the right upper extremity. He had undergone several operative procedures to stabilize the elbow since the injury, but his elbow function remained limited. All of the previous surgeries had been performed under general anesthesia (GA) with an IV PCA for post operative pain control. Due to the potential risk of nerve injury with regional anesthesia (RA), peripheral nerve blockade has traditionally been considered a relative contraindication in HNPP patients. Unfortunately, this patient had significant issues with pain control following his prior surgeries, and the pain limited his ability to participate in therapy, resulting in a suboptimal surgical outcome. Outcome: After much discussion regarding risks and benefits of RA, we agreed to perform a supraclavicular block for the primary surgical anesthetic. The goal was for the patient to be able to participate in early physical therapy. A supraclavicular catheter was successfully placed under ultrasound guidance and bolused with 30ml of 0.5% ropivacaine. The patient was sedated with propofol during the case. Upon arrival to the PACU, the patient was started on a low dose perineural infusion of 0.2% ropivacaine at 10ml/hour. The patient frequently reported pain scores of 2/10 and had full return of motor function the evening of surgery. The patient fully participated in physical therapy on post-operative day one, and was discharged home with an ambulatory pain pump infusing 0.2% ropivacaine. The patient was very satisfied with his postoperative analgesic therapy and no residual motor or sensory deficits were noted. He reported excellent elbow function upon follow-up. HNPP - Background info: Hereditary Neuropathy with liability to Pressure Palsies (HNPP) is an autosomal dominant progressive neurologic disorder causing the individual to be highly susceptible to nerve injury resulting from pressure, stretch or repetitive use. Following injury, the nerve demyelinates leading to sensory, motor, or combined neurologic deficit. The palsy can range from mild and nonlimiting to severe and long lasting. The peroneal nerve, ulnar nerve, radial nerve, and median nerve are most commonly affected. This disorder can be seen in 16 of 100,000 people in the general population. Discussion: Little information exists in the literature with regard to regional anesthesia in patients with HNPP. Many experts advise avoiding nerve blocks in patients with risk factors for neurological injury. This case is unusual and interesting in that the patient had a rare genetic neurologic disorder with direct anesthetic implications. Although relatively contraindicated, it was felt that the risk-benefit ratio favored regional anesthesia, as the patient´s prior surgeries had limited success due to poor post-operative pain control. Careful placement of this block, with slow injections under ultrasound guidance resulted in an excellent outcome without complication. A188 SUBDURAL SPREAD OF LOCAL ANESTHETIC DURING LUMBAR PLEXUS BLOCK: A CASE FOR THE TEST DOSE J. Ghassemi, N. Stites-Hallett, P. Aleshi, M. Braehler Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA Introduction: Numerous case reports describe unintentional subdural injection of local anesthetic during subarachnoid or epidural anesthesia. Inadvertent placement of local anesthetic in the subdural potential space may also occur during performance of lumbar plexus blockade. Clinical presentation may go unrecognized or be attributed to other causes. A high clinical suspicion in addition to testdose utilization could allow for early detection and prevent further consequences. Case: Lumbar plexus blockade with catheter placement is a commonly performed technique for intraand post-operative analgesia during hip arthroplasty at our institution. We present a case of a 56 year-old female with osteoarthritis of her left hip and two prior hemiarthroplasties who was scheduled for a revision surgery of her left hip. She consented to preoperative placement of a left lumbar plexus injection and catheter for intra- and post-operative analgesia. After right lateral decubitus positioning, sterile preparation and draping, the patient received Fentanyl 100 mcg and Midazolam 2 mg IV with calming effect. The patient received skin infiltration with lidocaine 2% (3 mL). We used a 10-cm 18-gauge nerve-stimulating needle to elicit an isolated quadriceps muscle twitch down to 0.5 mA at a needle depth of 8.5 cm. After negative aspiration, we injected a test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine. Within 2.5 minutes the patient had loss of sensation to touch, cold, and pin prick and within 5 minutes, she was unable to move her left lower extremity and became hypotensive with a systolic blood pressure of 90 mmHg. During this time, the needle was removed and catheter placement was aborted. The patient was adequately resuscitated with fluids and vasopressors. Within 15 minutes her block peaked to C7 bilaterally yet she retained 5/5 motor strength in her right lower extremity; within one hour she had return of motor and sensory function in her left lower extremity. Discussion: While the possibility for inadvertent epidural or intrathecal injection exists when performing lumbar plexus blockade, we believe that the likelihood of a subdural injection in our case is strong given the disproportionate extent of sensory block with relation to the total amount of local anesthetic administered as a test dose. Consequences of inadvertent subdural injection may vary in their clinical severity. By administering a test dose prior to injection and catheter placement, we were able to avoid potentially catastrophic complications from this lumbar plexus block. Our case of presumed subdural spread of local anesthetic while performing a lumbar plexus block serves to raise awareness of the critical complications of this technique and suggest early recognition of subdural injection by using a test dose. References: 1. Agarwal D, Mohta M, Tyagi A, Sethi AK. Subdural Block and the Anaesthetist. Anaesthesia and Intensive Care, 2010;38:1. 2. Boezaart A. Is There Something Else We Should Know to Prevent Complications: Microanatomy of the Peripheral Nervous System Revisited, And Its Implications for Paravertebral Blocks. Lecture: OAPRS, October 2008. A189 ULTRASOUND-GUIDED PARAVERTEBRAL BLOCK IN A MORBIDLY OBESE PATIENT WITH ANTERIOR MEDIASTINAL MASS, OBSTRUCTIVE SLEEP APNEA, AND CHRONIC PAIN REQUIRING SURGERY: ACHIEVING SAFETY AND COMFORT J. Ghassemi, L. Lin Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA Introduction: The anesthetic management of patients with an anterior mediastinal mass remains a challenging and perilous endeavor to anesthesiologists. These tumors can cause severe airway and vascular compromise, effects that may be exacerbated in the comorbid patient. Administering general anesthesia to such patients increases the risk of cardiovascular and respiratory collapse. Anesthetic approaches—including regional anesthesia—that avoid general anesthesia for patients with an anterior mediastinal mass requiring surgery may reduce this risk and improve outcomes. We present a case of a medically challenging patient with a symptomatic, large anterior mediastinal mass who received a single-shot thoracic paravertebral block and light sedation for scheduled surgery. Case: A 47-year old female with progressive dyspnea and chest radiograph findings of a large leftsided pleural effusion, rightward cardiac shift, and a large right upper lobe consolidation consistent with an anterior mediastinal mass—suspicious for lymphoma—was scheduled for an incisional left axillary lymph node biopsy. Preoperative chest CT confirmed the large pleural effusion causing complete left lower lobe and partial left upper lobe collapse; it also demonstrated a large mass infiltrating the mediastinum extending superiorly, with obstruction involving both the airways and major vasculature (complete right jugular vein obstruction and left subclavian and brachiocephalic vein narrowing). Complicating the patient's clinical status was a history of morbid obesity (BMI=34), obstructive sleep apnea, and chronic pain from genital herpes simplex virus. Given a concern for potential hemodynamic and respiratory complications in this comorbid patient with a symptomatic anterior mediastinal mass, general anesthesia was regarded as a high risk option. Instead, we decided to proceed with a regional anesthetic block and minimal systemic sedation. A left-sided, T1 single-shot paravertebral block was performed with real-time ultrasound guidance using a transverse view and an in-plane approach. The patient was seated for the procedure, standard ASA monitors were placed, and supplemental oxygen via nasal cannula provided. Local anesthesia was achieved via infiltration of subcutaneous tissues with 1% mepivacaine. After confirming needle-tip visualization in the paravertebral space, 10-mL of 0.5% ropivacaine was injected without complications. The patient tolerated the procedure and subsequent surgery well, and required only midazolam 1 mg and fentanyl 25 mcg intravenously for light intraoperative sedation. Discussion: Fatal airway obstruction or cardiovascular collapse in patients with a large anterior mediastinal mass under general anesthesia is well documented, a risk that is exacerbated with the above comorbidities. While general anesthesia is sometimes unavoidable, a regional technique when feasible elegantly avoids those dangers. When presented with a comorbid patient with an anterior mediastinal mass and the heightened risks that a general anesthetic or deep sedation would entail, we opted to perform a regional anesthetic technique—a left-sided, T1 single-shot paravertebral block—to achieve effective anesthesia while optimizing patient safety. References: 1. Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol. 2007;20:1-3. 2. Gothard JWW. Anesthetic Considerations for Patients with Anterior Mediastinal Masses. Anesthesiology Clin. 2008; 26:305-314. [Ultrasound-guided Paravertebral Block] A190 HYDRODISCECTOMY - A PERCUTANEOUS TECHNIQUE TO TREAT RADICULAR PAIN FROM CONTAINED LATERAL LUMBAR DISC HERNIATIONS 1 1 S. Gianoukos , R. Pitts , F.J. Gerges 1,2 1 Department of Anesthesiology and Pain Medicine, Pain Management Center, Department of Anesthesiology and Pain Medicine, Steward St. Elizabeth's Medical Center, Brighton, 2 3 Anesthesiology, Tufts University School of Medicine, Boston, Pain Medicine Fellowship, St. 4 Elizabeth's Medical Center, St. Elizabeth's Pain Management Center, St. Elizabeth's Medical Center, Brighton, MA, USA Percutaneous disc decompression (PDD) techniques are increasingly being offered to patients with contained disc herniations. They offer an alternative to minimally invasive spine surgery. Hydrodiscectomy (Hydrocision, North Billerica, MA, USA), specifically, employs a high-pressure water jet to simultaneously resect and remove nuclear material, while preserving the surrounding tissue. We present a patient who benefited greatly from this procedure with complete resolution of his radicular symptoms. Patient gave consent for this publication. Case report: A 43-year-old otherwise healthy male, presented to our Pain clinic with low back pain radiating to his left posterior thigh, calf and sole of the foot. His pain was shooting, 5/10 on VAS scale, worse with coughing, walking or bending. He had undergone conservative therapy with NSAIDs, heat/ice, and physical therapy for three months, with minimal relief. On physical examination, he had a positive left Straight Leg Raise. Lumbar MRI showed L5-S1 moderate left lateral disc protrusion compressing the left L5 nerve root (Fig 1). He underwent four Lumbar Epidural Steroid Injections over six months with 80% reduction of his symptoms for only 3-4 weeks following each injection. At this point, he underwent a left-sided L5-S1 Hydrodiscectomy (Fig 2). At his 2 weeks follow-up, his back pain was 1/10 and the radiating pain to his leg had completely resolved. [Figure 1-Lateral Left L5-S1 Disc Herniation on MRI] [Figure 2-Resector Insertion via Perc Cannula] Discussion: Surgical approaches to disc decompression are accompanied by a number of damaging sequelae, such as annular incompetence, epidural fibrosis, and formation of scar tissue around the nerve. In addition, data have shown that the recurrence rate of lumbar disc herniation following 1 Microdiscectomy is as high as 26%. PDD aim to reduce intradiscal pressure in the nucleus and thereby create space for the contained herniated disc fragment to retract inwards. As a result, there is a reduction of nerve root compression, thus less radicular pain. The goal of Hydrodiscectomy, specifically, includes pulverizing a quantifiable amount of disc material and removing it via an evacuation tube. Only a 4-mm annulotomy is required, through which 15% of the nucleus is removed. Advantages include: lack of nerve root manipulation, scar tissue formation, and epidural fibrosis. It is done under local anesthesia/sedation in an outpatient setting, with the ability to return to work within one week. A recent report showed 94% short term improvement < 6 Month in 2 lower back and radicular pain . We believe that Hydrodiscectomy bridges the gap between failed conservative therapy and Microdiscectomy for patients with contained lateral disc herniations causing unilateral radicular symptoms. However, well-designed, prospective case-controlled trials are needed to determine its long term efficacy and safety. References: 1- Carragee EJ, et al. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and annular competence. J Bone Joint Surg Am. 2003; 85-A(1):102-8. 2- Hardenbrook MA, et al. Clinical Outcomes of Patients Treated with Percutaneous Hydrodiscectomy for Radiculopathy Secondary to Lumbar Herniated Nucleus Pulposus. The Internet Journal of Spine Surgery. 2013 Volume 7 Number 1. A191 REVISION TOTAL SHOULDER ARTHROPLASTY WITH UNRECOGNIZED SUBCLAVIAN ARTERY ANEURYSM RUPTURE B. Golbaba, M. Isenhower, S. Clendenen, R. Greengrass Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA Introduction: Aneurysms of the upper extremity are extremely rare accounting for only 1% of all [1] peripheral aneurysms; of these, subclavian aneurysms are the most common . Subclavian aneurysms and pseudoaneurysms can present with a number of symptoms including hoarse voice, dysphagia, stridor, extremity numbness/tingling and ischemic signs. Known causes include [2] [3,4] atherosclerosis, thoracic outlet syndrome, and trauma (blunt trauma , IJ cannulation complication ). Recognition of aneurysmal rupture is essential as it is potentially life and limb threatening with known [5] sequelae including nerve compression (brachial plexus , stellate ganglion, recurrent laryngeal), tracheal compression, thromboembolism, limb ischemia, and life-threatening hemorrhage. We report a case of ischemic neuropathy secondary to aneurysrmal rupture attributed to motor block associated with an interscalene catheter. Case report: A 70 year old female with history of hyperlipidemia, asthma, rheumatoid arthritis, left breast cancer s/p chemo-radiation, and previous left shoulder arthoplasty complicated by infection was scheduled for left shoulder arthrotomy with soft tissue debridement and humeral head exchange . An uncomplicated ultrasound guided interscalene catheter was placed for postoperative analgesia and dosed with 20 cc of 0.5% ropivacaine . Her intraoperative course was complicated by significant blood loss and hypotension for which she received blood transfusions and vasopressors. She remained hypotensive in PACU and a right internal jugular central as well as radial arterial line were placed. Lab investigation revealed an acute postoperative coagulopathy with a hematocrit of 23.7, platelet count 93k and INR of 1.7. She received replacement therapy and her coagulopathy subsided. It was noted that the patient was complaining of significant pain despite complete motor block. She received hydromorphone PCA to supplement the local anesthetic interscalene infusion (6c/hr 0.2% ropivicaine with 6 cc bolus q 60 minutes). On postoperative day (POD) 1, the patient's arm was noted to be ecchymotic with pitting edema. Shoulder and arm pain persisted despite a complete motor block. On POD 2, the patient was noted to have increased arm swelling. CT examination revealed a left subclavian pseudoanyerusm and hematoma with mass effect which was confirmed with angiography. Radiology placed a stent graft and her interscalene catheter was removed prior to returning to the OR for hematoma evacuation. Discussion: Neurologic injury including brachial plexopathy has been reported secondary to subclavian pseudoaneurysm. Prompt diagnosis and treatment is crucial to prevent permanent injury. The ischemic neuropathy observed in our patient was incorrectly attributed to motor block from the regional catheter however ongoing pain prompted further investigation and revealed the correct [6] diagnosis. Studies of ischemic pain secondary to compartment syndrome have also revealed a breakthrough pattern. Whenever significant pain occurs in the presence of a functional regional catheter alternative diagnoses such as ischemic neuropathy should be contemplated and investigated. Sources: th 1. Townsend, C. Sabiston Textbook of Surgery. 18 Ed. New York: Saunders; 2007. 2. Serrano, J. Acta Orthopædica Belgica, Vol. 69 - 6 - 2003 3. Modi MP. Indian J Crit Care Med 2007:11;93-5 4. Pastores SM. Am J Crit Care. 1995;4(6):472-5. 5. O´leary MR. Am J Emerg Med. 1990;8(2):129-33. 6. Walker BJ. Reg Anesth Pain Med. 37(4):393-7. A192 COMBINED SUPERFICIAL CERVICAL PLEXUS AND “PECS BLOCK” FOR PACE MAKER/ AUTOMATIC INTERNAL CARDIAC DEFIBRILLATOR INSERTION B. Golbaba, C. Robards, C. James Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA Introduction: Pacemaker(PM) and (AICD) insertion has increasingly become a procedure requiring the expertise of an anesthesiologist due to the moribund status of the patient population requiring [1] these devices . The physiologic changes associated with general anesthesia and sedation with field local anesthetic may not be tolerated by a large number of these patients. Several regional techniques for pacemaker insertion have been described in the past but are not commonly used by [2,3] most practicing anesthesiologists . We describe a regional anesthetic method utilizing a superficial cervical plexus (SCP) block combined with a “Pecs block” to provide surgical anesthesia for a patient with significant cardiac history that required PM/AICD insertion. Materials and methods: A 74 year old male with history of coronary artery disease, hypertension, diabetes mellitus, chronic renal failure and peripheral vascular disease who was admitted for myocardial infarction was found to have severe left ventricular dysfunction (ejection fraction 18%). During hospitalization he was placed on an intraaortic balloon pump (IABP) to augment cardiac output. Following weaning of the IABP, the patient went into flash pulmonary edema requiring mechanical ventilation. Cardiolgy determined that the patient would benefit from a PM/AICD. After standard ASA monitors were applied and following cleansing of the left anterior chest wall with chlorhexidine, a Philips Sparq Ultrasound machine equipped with a linear L12-4 probe was used to identify the pectoralis major and pectoralis minor muscles. Using a 22 gauge touhy needle, 10 ml of 0.5% ropivacaine was deposited between the pectoralis major and pectoralis minor muscles, similar [4] to the technique described by Blanco et al . Following that, we then performed a left sided SCP block, depositing 10 cc of 0.5% ropivacaine along the posterior border of the sternocleidomastoid at the level of the C6 vertebrae transverse process down. A total of 50 mcg of IV fentanyl was titrated to effect for the two block procedures. Results: The patient underwent the pacer insertion procedure, lasting 200 minutes, comfortably. A total of 75 mcg of fentanyl was given along with 10 mcg/kg/min of propofol; the patient was able to respond to command during the procedure at all times. The patient was very comfortable in the recovery area and well into the following day, requiring essentially no analgesics. [PEC Block] Discussion: In this clinical case, we found that the utilization of a SCP in conjunction with a “Pecsblock" provided surgical anesthesia for PM/AICD insertion thus minimizing anesthesia and the physiologic perturbations associated with general anesthesia or heavy sedation. References: 1. Veve I, Melo LF. Anesthesia for Pacemaker Insertion. Seminars in Cardiothoracic and Vascular Anesthesia. 2000;4(3):138-143. 2. Raza SM, Vasireddy AR, Candido KD, Winnie AP, Masters RW. A complete regional anesthesia technique for cardiac pacemaker insertion. J Cardiothorac Vasc Anesth. 1991;5(1):54-6. 3. Martin R, Dupuis JY, Tetrault JP. Regional anesthesia for pacemaker insertion. Reg Anesth. 14(2):81-4. 4. Blanco R. The ´pecs block´: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66(9):847-8. Funding Disclosure: Nothing to disclose. Personal Conflicts of Interest Disclosure: Nothing to disclose. A193 INFRACLAVICULAR NERVE BLOCK IN A PATIENT WITH INCLUSION BODY MYOSITIS M.C. Grant, E.A. Freck Johns Hopkins Hospital, Baltimore, MD, USA Objective: To describe the anesthetic plan and postoperative course of a patient with inclusion body myositis undergoing outpatient right hand metacarpophalangeal fusion and extensor to flexor tendon transfer. Regional anesthesia for inclusion body myositis has not been described in the literature. Case description: Patient MK is a 67 year old female with a five year history of progressive bilateral lower extremity proximal muscle wasting was well as bilateral wrist flexion and neck flexion weakness. Progression of symptoms necessitated muscle biopsy. Biopsy confirmed moderately severe, chronic myopathy with red-rimmed vacuoles consistent with inclusion body myositis. Her medical history was also significant for psoriatic arthritis, osteoarthritis s/p cervical discectomy and hypertension. Home medications included dicyclomine, diclofenac, tizanidine and Humira. She further reported occasional outpatient opioid prescriptions in conjunction with various arthritic flares and minor surgical interventions. Furthermore, the patient carried a questionable history of asthma which may be attributed to axial muscle weakness associated with her myositis diagnosis. Focused physical exam revealed 4/5 strength to wrist flexion bilaterally, markedly decreased grip bilaterally, 4/5 iliopsoas and ankle flexion/extension bilaterally. Gait was slow and deliberate. Given worsening fine motor disturbance and poor hand coordination, she was scheduled as an outpatient for right thumb metacarpophalangeal joint fusion with right index finger extensor to flexor tendon transfer. Our anesthetic plan for this patient included the following: (A) Preoperative single shot infraclavicular block with 30ml 0.25% bupivacaine with 1:200k epinephrine. The patient's operative arm was abducted 90° with needle insertion site medial & inferior to the coracoid process. Needling was ultrasound-assisted with an in-plane approach using a high frequency linear probe. Infraclavicular block permitted us to avoid potential risk of phrenic nerve block with a supraclavicular approach. Given her muscle weakness incorporated both peripheral and proximal muscles and the outpatient nature of the surgery, we wanted to avoid any potential for respiratory compromise. This also provided useful postoperative analgesia to address potential chronic pain symptoms given multiple opioid adjuncts on an outpatient basis. (B) Maintenance anesthetic with inhaled fluorinated agent (general anesthesia) with LMA. Given the length of surgery and precision necessary for the procedure as well as by request of the patient, we elected to perform general anesthesia. In order to avoid neuromuscular blockers in light her myositis diagnosis, we utilized LMA placement for airway support. Postoperatively, the patient did well. She was monitored per our typical institutional outpatient PACU protocol and discharged home without apparent anesthetic or surgical complication. Her block lasted approximately 12 hours and she tolerated low dose oral oxycodone thereafter for pain control. Initial surgical follow-up was encouraging, as within 10 days of her procedure she attained dramatic improvement in fine motor dexterity in her operative hand. This case illustrates the anesthetic challenges associated with an outpatient orthopedic procedure on a patient with both chronic pain and inclusion body myositis. Our strategy carefully addressed the need for appropriate surgical exposure while limiting known risks associated with our patients unique medical characteristics. A194 RECTOSIGMOID RESECTION FOR TUMOR IN A PATIENT WITH DILATED CARDIOMYOPATHY USE OF BILATERAL TRANSVERSUS ABDOMINIS PLANE (TAP) CATHETERS AND PCA FOR POST-OPERATIVE PAIN MANAGEMENT J.S. Green, A. Kreitz, B.C.H. Tsui, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Single-shot transversus abdominis plane (TAP) blocks can reduce morphine 1 requirements in patients undergoing abdominal surgery. In our practice, a multimodal regime utilizing TAP blocks in combination with other analgesics is standard practice for many operations requiring lower abdominal incision. This case report describes the use of TAP catheters to manage pain in a difficult case of abdominal surgery. Patient consent was obtained prior to describing this case. Material and methods: A 49-year-old male with a recent history of dilated non-ischaemic cardiomyopathy, congested heart failure, NYHA functional classification 4, and an ejection fraction of 15% presented for rectosigmoid resection with end colostomy for sigmoid colon tumor. Additional medical history included 2:1 atrial flutter, paroxysmal AF, COPD, morbid obesity (BMI 40.5), suspected obstructive sleep apnoea, hypothyroidism, and smoking. Prior to surgery, the patient was optimized medically with diuretics and ACE inhibitors, improving his functional status to NYHA 3A. No further optimization was possible and he was keen to proceed to surgery despite the high risk of perioperative morbidity. Due to his complex cardiac history he was managed by a cardiac anesthetist intraoperatively, and his cardiovascular system was supported by inotropes (dobutamine) and vasopressors (norepinephrine) during surgery. Trans-esophageal echo was used for intra-operative monitoring, and ICU admission was planned post-operatively. The acute pain service was consulted for post-operative pain control, and a multimodal pain control regimen, including bilateral TAP catheters and morphine PCA was advised. Surgery proceeded uneventfully. Results: The TAP catheters were inserted postoperatively under ultrasound guidance superior to the iliac crest in the mid-axillary line and bolused with 20 mL 0.2% ropivacaine. A continuous infusion of 1mL/hr 0.2% ropivacaine was then started with a 20 mL bolus regime every four hours to each side. The patient was transferred to ICU post-operatively, and PCA morphine was commenced prior to successful extubation the following morning. Pain control was managed satisfactorily, allowing compliance with physiotherapy, deep breathing, and effective cough. Reported pain scores ranged from 2-5 on the 0-10 scale, and the patient was ambulatory on post-operative day one. Morphine PCA use was 26 mg for the first 24 hours and 30 mg for the second 24 hours. The TAP catheters were discontinued on post-operative day three, and pain control remained satisfactory with PCA and then oral analgesia until discharge. Discharge was delayed until post-operative day 23 due to postoperative ileus and then right portal vein thrombosis. Discussion: For this complex case, we had to consider the planned ICU admission and time delay until extubation. We therefore elected to place TAP catheters rather than single-shot blocks to ensure optimal analgesia at the time of extubation. This technique proved successful at providing good quality analgesia and can be considered in similar difficult cases. References: 1. Petersen PL, et al. Acta. Anaesthesiol. Scand. 2010; 54: 529-535 Funding disclosure: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest disclosure: Nothing to disclose. A195 ACUTE PAIN: LONG STANDING RHEUMATOID ARTHRITIS (RA) IN MIDDLE AGED FEMALE S. Griffee, T. Oh Mayo Clinic, Rochester, MN, USA Introduction: Two middle-aged female patients, with over 20-year history of RA presenting with acute onset of upper limb pain. Material and methods: Case #1: 52 year old female with 25 year history ofRA, requiring multiple surgeries including wrist fusion, and shoulder arthoroplasty presented to outpatient clinic for exercise recommendations. Patient's current exercise routine included 20 minutes daily walking, 15 minutes daily biking, and once weekly 30 minutes of 4-pound kettle bells. Joint symptoms were well controlled on methotrexate, abatacept and prednisone 5mg daily. She denied joint pain, except for pain in the left shoulder, most notable during Kettlebell exercise. Exam demonstrated limited joint motion of bilateral wrists, tenderness in the left shoulder and no significant synovitis. All other joints had full ROM. X-rays of the right wrist revealed radiocarpal artrodesis with plate and screw fixation and fractures of the 2 fixation screws in the scaphoid. Case #2: 44-year-old female with 20-year history of RA. Patient with significant recent weight gain and obesity, . Exercise routine included patient had recently joined a gym. Joint symptoms were well controlled on methotrexate, Plaquenil, and Aleve. She admitted to hand and wrist pain noted after workouts . Exam demonstrated limited motion of the wrist, swan neck and mild swan neck eformities of the wrist, with subluxation of the MTP joints of the toes. X-ray revealed erosive changes in the second MCP joints of the hands and MTP joints of the feet. Discussion: In this case series, both patients presented with a long history of RA, but both were unaware of exercise modification needed specifically for compromised joints. In Case #1, patient with improper selection of exercise. Specifically kettle bell swings causing significant stress on a compromised joint resulted in schaphoid fracture and shoulder pain. In Case #2, patient with limited exercise, because of limited knowledge of proper exercise modification resulted in sedentary lifestyle with weight gain adding significant stress to joints. On initial assessment both patients were unaware of specific exercise limitation. Results: After further review of exercise/past history, physical evaluation, and review of imaging, it was determined that lack of exercise knowledge was a contributing factor to injury demonstrated on imaging. Both were counseled on joint protection and referred to physical therapy for review of exercise principles and proper technique for strengthening exercises. Conclusion: This case series highlights that patients with long standing RA are often not aware of proper exercise modification and joint protection principles. Specifically in women with RA, exercise options are often not discussed until pain or injury presents. In conclusion, physician encounters should include: review of the current exercise program (cardiovascular, strengthening, core stability and previous exercise history), review medication, past medical/surgical history, imaging suspected fractures, evaluation of gait and posture, inflammatory markers, and nutritional status. Counseling about joint protection principals, alternative exercises such as Tai Chi, and referral to physical therapy should be considered. A196 PARSONAGE-TURNER SYNDROME FOLLOWING INTERSCALENE CATHETER PLACEMENT R. Guha, M. Donnelly, K. Schroeder University of Wisconsin, Madison, WI, USA Introduction: Parsonage-Turner syndrome (PTS) is characterized by acute, severe neurogenic pain in the shoulder or arm lasting for several days or weeks. This is followed by muscle weakness, atrophy, and sensory loss as the pain diminishes. Both hereditary and acquired forms exist, with viral infections, immunizations, strenuous exercise, and surgical procedures cited as causes. The diagnosis is primarily clinical, supported by EMG and MRI. The condition usually completely resolves over time and there is no definitive treatment otherwise. There is one case in the literature of PTS following and interscalene block (ISB). We present a case of PTS following and interscalene catheter (CISB) and a subsequent ISB during the course of the patient´s PTS. Case description: A 51yo female with a history of low back arthritis underwent an arthroscopic right shoulder rotator cuff repair, subacromial decompression, biceps tenotomy, and distal clavicle excision. Prior to surgery, she experienced nine months of pain in her right shoulder with no specific antecedent injury, as well as hand numbness. For surgery, a CISB was placed using ultrasound guidance (USG) via the posterior approach. The catheter was test dosed, then dosed with bupivacaine with 1:400,000 of epinephrine. Postoperatively, the patient had difficulty achieving adequate pain control with the CISB, oral oxycodone, and ketorolac. Soon after the CISB was removed, oxycontin was added. The patient continued to have considerable difficulty with pain control but this gradually improved. Two months postoperatively, she had an atraumatic dislocation of her shoulder, and suspicion was raised for PTS. The surgeon felt that paralysis of the supraspinatus, infraspinatus, and deltoid muscles was developing from PTS. Three months after her initial surgery, the patient underwent right shoulder open reduction, for which she received an USG ISB again with bupivacaine and epinephrine. Her shoulder became dislocated again in the recovery room, but was reduced in closed fashion. An EMG showed right suprascapular neuropathy and coexisting right axillary neuropathy. This EMG in conjunction with her symptoms supported a diagnosis of PTS. The patient continued with physical therapy and opiates as needed for pain. Three months after her second operation, her shoulder remains reduced and pain much improved, with significantly decreased opiate use. A numb patch persists over her deltoid and deltoid strength remains limited, but overall strength is improved. Discussion: Interscalene blocks have been proposed as a possible mechanism for PTS, although this is based on isolated case studies. Either surgery or interscalene catheter placement may have contributed to PTS in this case; the patient denied other potential triggers. The clinical picture suggests that it began after the initial surgery, classically presenting with pain initially and delayed motor symptoms. Following shoulder surgery and ISB, severe pain that does not respond to usual treatments should lead us to consider PTS as a diagnosis. References: Idiopathic Brachial Plexitis After Total Shoulder Replacement with Interscalene Brachial Plexus Block. Tetzlaff et. al. Anesthesia and Analgesia 1997; 85: 644-6. Neuralgic Amyotrophy (Parsonage-Turner Syndrome). Tjoumakaris et. al. Journal of the American Academy of Orthopedic Surgeons 2012. 20 (7): 443-9. A197 POST DURAL PUNCTURE HEADACHE AFTER THORACIC EPIDURAL TREATED WITH BLOOD PATCH UNDER FLUOROSCOPY P. Hagan, K. Hagan, K. Schroeder 1 2 Anesthesiology, University of Wisconsin Hostpital and Clinics, Madison, WI, USA Introduction: Thoracic epidural blood patches (TEBP) are becoming increasingly important. This is partially secondary to increased recognition of spontaneous dural tears as a cause of positional headaches. TEBP is also occasionally required when iatrogenic injury (i.e. inadvertent “wet tap”) is the cause of dural tear. A TEBP can be technically challenging for the anesthesiologist and little data exists to guide any therapeutic intervention. Case study: A 53 year old male patient presented for colovesicular fistula repair, sigmoid resection, and loop ileostomy. A thoracic epidural was planned for postoperative analgesia. The resident first attempted to access the epidural space via a midline approach at approximately T9-10, but unsuccessful secondary to bony contact. The faculty anesthesiologist was subsequently able to enter the epidural space via the paramedian approach. Of note, there was an acute needle “step-off” prior to obtaining a loss of resistance but no fluid was noted to flow from the Tuohy. No fluid was returned with aspiration of the epidural catheter and the test dose of 3mL 1.5% lidocaine with 1:200,000 epinephrine was negative. The planned surgical procedure was completed without complications and an infusion of ropivacaine with hydromorphone was initiated in the recovery room. On POD #2, the patient began complaining of a positional headache. Following failure of caffeine supplementation and acetaminophen therapy, a TEBP through the in-situ epidural catheter was planned. Despite a two day functioning epidural infusion and removal of the bacterial filter, the block team was unable to inject any blood though the epidural catheter. A standard TEBP was then offered, but the patient declined. On POD#3 the patient's surgical pain was controlled with oral narcotics and he was tolerating a diet. The patient's headache persisted and he was counseled that a bedside attempt at a TEBP was likely to be difficult, given the technical difficulty with his initial epidural catheter insertion. Because of this, interventional radiology was consulted for the TEBP procedure. At the request of the interventional radiologists, a thoracic spine MRI was performed which demonstrated normal anatomy. On POD#8, a fluoroscopically guided blood patch was performed at the T10-11 level with a 22 gauge needle. Contrast was utilized to confirm positioning of the needle in the epidural space. 10mL of autologous blood was then injected. The patient had great improvement in his headache and was discharged home on POD#10. Conclusions: Inadvertant thoracic dural perforation is relatively uncommon compared to the lumbar level during epidural placement and headaches following thoracic dural puncture occur rarely. Most of the teaching regarding EBP focuses on lumbar approaches. There are a number of questions that need to be addressed regarding TEBP including, volume of blood required, safety of injection of large volumes of blood adjacent to spinal cord, potential utility of performing lumbar EBP in the setting of a thoracic dural puncture, how to evaluate a patient with back pain following TEBP and should fluoroscopy be routinely considered when performing epidural blood patch in the thoracic region. A198 BARTH SYNDROME: A REGIONAL ANESTHETIC APPROACH TO REDUCE PERI-OPERATIVE CARDIAC MORBIDITY AND MORTALITY IN A PEDIATRIC PATIENT 1 2 1 D.M. Hall Burton , C.P. Honsinger , M. Visoiu , A. Davit 1 1 2 Anesthesiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, Anesthesiology, 3 University of West Virgninia, Morgantown, WV, Anesthesiology, Children's Hospital of Pittsburgh of 4 UPMC, Plastic Surgery, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA Introduction: Barth syndrome is a rare fatal x-linked disorder of lipid metabolism caused by a mutation of the tafazzin gene that impairs cardiolipin formation and compromises mitochondrial function.(1) Barth syndrome is characterized by progressive and fatal dilated cardiomyopathy, proximal myopathy, neutropenia, growth retardation, organic aciduria, and feeding difficulty.(2) Case report: A 17 month-old 8 kg male with Barth syndrome and associated dilated cardiomyopathy, combined systolic and diastolic heart failure, neutropenia, and mild mitral insufficiency presented for excision of right radial polydactyly and radial collateral ligament reconstruction. In patients with significant cardiomyopathy, anesthetic related vasodilatation, bradycardia, and myocardial depression can cause catastrophic hemodynamic instability. Pain can cause increased peripheral resistance, heart rate, stroke volume, myocardial work, and oxygen demand. Increased heart rate further limits coronary oxygen delivery. We determined that a balanced anesthetic of inhalation agent, opiate, and a brachial plexus nerve block would provide optimal peri-operative hemodynamic stability. After premedication with midazolam an inhalational induction was performed. A peripheral IV and LMA were placed. Anesthesia was maintained with a 0.5 MAC mixture of sevoflorane, nitrous oxide and oxygen. A supraclavicular nerve block was then performed. The block was performed in the classic supraclavicular position with the probe positioned in the transverse oblique orientation in the supraclavicular fossa. The subclavian artery, first rib, pleura, anterior and middle scalene, and brachial plexus were easily identifiable. A 22G 40mm Pajunk sonographic stimulating needle was inserted under ultrasound guidance and directed underneath the brachial plexus to the angle formed by the posterolateral aspect of the subclavian artery and the first rib. After negative aspiration, 8 mg ropivacaine was injected. Local anesthetic was seen surrounding the nerves. The surgical case was then completed without complication. The LMA was removed at the conclusion of the case and the patient was taken to the recovery room. Postoperatively the patient received acetaminophen and one dose of oxycodone prophylactically. He was pain free and motor function returned by post-operative day one. He was discharged on postoperative day two. Discussion: Patients with Barth syndrome present many challenges for the anesthesiologist. Anesthetic agents, opiates and post-operative pain can have significant morbidity or mortality. Ultrasound guided supraclavicular nerve blocks can be performed quickly with a low anesthetic. It allowed the patient to tolerate the surgical procedure and tourniquet minimal volatile anesthetic agent and opiate use. Using a low concentration of local limited its potential for myocardial depression. Post-operative pain was well hemodynamic instability occurred. volume of local placement with anesthetic also controlled. No The regional anesthetic minimized the patient's anesthetic and surgical risk. His procedure was completed with minimal anesthetic exposure, adequate pain control, and he was discharged to home on post op day two without complication. [Pre-Operative Radial Polydactyly] [Post-Operative Radial Polydactyly] 1. Gonzalez IL. Barth syndrome: TAZ gene mutations, mRNAs, and evolution. Am J Med Genet A 2005;134:409-414. 2. Barth PG, Wanders RJ, Vreken P. X-linked cardioskeletal myopathy and neutropenia. J Pediatr 1999;135:273-276. Nothing to disclose A199 RECTUS SHEATH NERVE BLOCK CATHETERS FOR MIDLINE ABDOMINAL INCISIONS IN PEDIATRIC PATIENTS: A REGIONAL ANESTHETIC APPROACH TO POSTOPERATIVE PAIN MANAGEMENT D.M. Hall Burton, J. Smolinski, M. Visoiu, I. Galay, A. Cassara Anesthesiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA Introduction: Epidural analgesia is the gold standard for abdominal surgical incisions, however co1 morbidities and side-effects limit its use. Peripheral nerve blocks are performed to provide analgesia in patients who are not candidates for neuraxial techniques or to minimize complications. Rectus 2 sheath catheters have been described for adult patients, but not for use with children. We encountered two pediatric patients with midline surgical incisions requiring post-operative analgesia. For each, we performed bilateral rectus sheath nerve blocks with catheters (RSNBC) for postoperative analgesia. Case 1: An 18 year-old 54 Kg female with Crohn's disease presented for laparoscopic ileocecectomy. The surgical approach involved a 5cm midline incision. Following surgery under general anesthesia, ultrasound guided bilateral RSNBCs were placed between the rectus muscle and sheath along the lateral edge of the muscle at umbilical level. Catheters were bloused with 10mL of 0.5% ropivacaine. In the post-anesthesia care unit (PACU), nerve block infusions of 0.2% ropivacaine at 5ml/hr per side with 1ml/hr clinician bolus were started. Visual analog scale (VAS) pain scores and opiate use are listed in Figure 1. Post-operatively she received acetaminophen every 6 hours for 4 days. POD 2 pain was intermittent sharp “gas” type pain. Nerve block infusions were suspended on POD 3, and her pain increased to VAS 7-10/10. Catheters were bolused and infusions restarted. On POD 4, catheters were suspended and her VAS increased from 2-5/10. Catheters were then removed. She identified a numb area along the midline from T7-T12 for the blocks' duration. [Figure 1] Case 2: A 13 year-old 69 Kg male presented for exploratory laparotomy and removal of ingested foreign body. The surgical approach involved a 4cm midline incision. Following surgery under general anesthesia, ultrasound guided bilateral RSNBCs were placed between the rectus muscle and sheath along the lateral edge of the muscle at umbilical level. As the catheters were bloused with 5mL of 0.5% ropivacaine, an ellipsoid shape was noted as the rectus muscle pushed away from the sheath. Nerve block infusions of 0.2% ropivacaine at 8mL/hr with a 2mL/hr clinician bolus were started in the PACU. Acetaminophen was given every six hours for three days. FLACC scores and opiate use are listed in Figure 2. RSNBCs were suspended on POD 3 and removed without complication. [Figure 2] Discussion: As an alternative to continuous epidural analgesia for midline abdominal incisions in pediatric patients, we attempted rectus sheath nerve block catheters. Both times, catheters easily and effectively provided sensory analgesia from T7-T12. No side effects or complications from the nerve blocks were noted. Opiate use was minimal and the patients were satisfied. Additional studies are needed to further assess continuous rectus sheath nerve blocks in pediatric patients. References: 1. Brown DL. Spinal, epidural, and caudal anesthesia. Miller's Anesthesia. 7th ed. Philadelphia: Churchill Livingstone, Elsevier Inc; 2009. P. 1611-8. 2. Sandeman DJ, Dilley AV. Ultrasound-guided rectus sheath block and catheter placement. ANZ Journal of Surgery 2008; 78: 621-3. Personal conflicts of interest disclosure: Nothing to disclose. A200 INTRAVASCULAR FEMORAL NERVE CATHETER RESULTS IN CNS TOXICITY WITH LOWDOSE ROPIVACAINE A. Puri, M.W. Harbell, P. Aleshi Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA Introduction: Local anesthetic systemic toxicity (LAST) is a rare but well documented complication of regional anesthesia. The minimum dose of ropivacaine thought to produce toxicity is 3mg/kg. We report a case of an intravascular femoral nerve catheter (FNC) resulting in CNS toxicity with low-dose ropivacaine. Case report: A 43-year-old, 96-kg, ASA physical status II male scheduled for revision total knee arthroplasty underwent an ultrasound-guided femoral nerve block with 20mL of ropivacaine 0.5%, after which a FNC was placed for postoperative analgesia. He had an uneventful operative course under subarachnoid block and propofol infusion for sedation. Upon arrival to the PACU, he was hemodynamically stable, awake, and comfortable. The FNC infusion was started with ropivacaine 0.1% infusing at 8mL/hr. After 30 minutes, the patient became hypotensive and somnolent, but arousable. He complained of lightheadedness, perioral numbness, a metallic taste in his mouth and exhibited muscle twitching of his upper trunk and extremities. He received midazolam followed by a bolus of Intralipid and his blood pressure was supported briefly with fluid boluses and phenylephrine. Following the resolution of his symptoms, a test dose containing epinephrine was administered via the FNC (after a negative aspiration) resulting in a clear rise in heart rate, confirming the intravascular location of the catheter. Discussion: LAST remains a significant clinical concern when performing regional anesthesia. The incidence of LAST ranges from 7.5 to 20 per 10,000 peripheral nerve blocks, however the incidence 1 may be underreported. Systemic toxicity results from elevated plasma local anesthetic levels above a threshold level, most often due to inadvertent intravascular injection, and less frequently from systemic absorption of local 2,3 anesthetic from a tissue depot. This case is interesting because of the very low dose of ropivacaine that the patient received, a total of less than 1.1mg/kg including both the initial bolus preoperatively (100mg) and the infusion in the PACU afterwards (4mg). Assuming all of the ropivacaine was injected intravascularly, it is surprising that this dose resulted in CNS toxicity. It is also unclear whether the toxicity developed in response to the initial bolus, in which case the presentation was delayed or potentially masked by the propofol he received intraoperatively, or whether it resulted from initiation of the infusion in the PACU. Other factors such as the rate of injection, drug-drug interactions, or patient factors may ultimately help explain why this patient was susceptible to LAST. References: 1 Mulroy MF. Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures. Reg Anesth Pain Med 2002;27(6):556-561. 2 Di Gregorio G, Neal JM, Rosenquist RW, et al. Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med 2010;35(2):181-7. 3 Neal JM, Bernards CM, Butterworth JF, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010;35(2):152-61. Funding: None Personal conflicts of interest disclosure: Nothing to disclose. A201 MULTIDISCIPLINARY APPROACH TO A PATIENT WITH AN ATYPICAL ACUTE HEADACHE R. Harris, K. Schroeder Anesthesiology, University of Wisconsin, Madison, WI, USA A 38-year-old woman with history of seasonal migraine headaches presented to the ED seventy-two hours after the acute onset of a severe positional headache. Initial therapy consisted of IV fluid administration and opioid administration. Neurosurgery consultation and head/spine MRI's failed to reveal an etiology for the patient's persistent headaches. Fifteen days of persistent positional headaches prompted neurosurgery to request a therapeutic lumbar epidural blood patch (EBP) for treatment of presumed spontaneous intracranial hypotension (SIH). Following L3-4 EBP with 20 ml of autologous blood, the patient reported immediate relief of her positional headache. Positional headache symptoms returned three days later and a neurology consult then recommended a repeat EBP, this time performed by interventional pain specialists at T4-T5 under fluoroscopic guidance. After only transient improvement in positional headache symptoms, a third EBP was performed at C7T1 under fluoroscopic guidance. Failure of this third EBP to resolve positional headache symptoms prompted a CT myelogram. Results of the CT myelogram revealed a T6-7 dural tear. The patient underwent surgical repair of her dural tear the following day, and her headaches resolved rapidly. Discussion: SIH is a syndrome that can lead to persistent daily headaches. These headaches are most often orthostatic in nature, mimicking post-dural puncture headaches (PDPH). As acute and chronic pain practitioners, anesthesiologists will potentially be called upon to aid in the treatment of these patients. It is therefore important to understand the pathophysiology, diagnosis, and treatment of this condition. SIH may often occur when there is cerebrospinal fluid (CSF) leakage into the subdural or epidural space. The meninges, cerebral and cerebellar veins, as well as cranial nerves V, IX, and X are all pain-sensitive structures that may lead to discomfort if the normally buoyant brain becomes less buoyant secondary to decreased CSF levels. History alone should be enough to raise a very high level of suspicion, as these patients will often have a clear orthostatic component to their headaches. Cranial MRI will often show subdural/extrathecal CSF, enhancement of the meninges, engorgement of the venous structures, pituitary hyperemia, or sagging of the brain. These patients may present to their primary care physician, the ED, or a pain clinic, and anesthesiologists may be called upon to treat them. Conservative treatment generally includes bed rest, oral hydration, caffeine, and acetaminophen. EBP's have a reported efficacy of 80-90% on the first attempt in PDPH patients, and these may be more effective if done at the sight of the dural tear. Finally, definitive treatment for refractory headaches, as in our patient, is surgical repair of the structural defect. A coordinated multidisciplinary approach is required to optimize patient outcomes. This patient prompted a formal discussion between neurology, anesthesia acute pain service and interventional pain physicians to develop a protocol outlining the appropriate sequence/location of EBPs and who should be responsible for their placement. Plan concordance between care team members will allow for clear expectations when management consultation for patients with SIH occurs. Funding / Personal conflicts of interest disclosure: There are no conflicts of interest or external funding to report. A202 PERSISTENT PHRENIC NERVE PARESIS AFTER SHOULDER SURGERY UNDER SUPRACLAVICULAR BLOCK: REPORT OF TWO CASES S. Haskins, T. Quinn, A.C. Lee, V. Zayas Anesthesiology, Hospital for Special Surgery, New York, NY, USA Transient Phrenic Nerve Paresis (TPNP) occurs with an incidence of 13 - 100% after interscalene block (ISB).(1)(2) Persistent phrenic nerve paresis (PPNP) has been reported after interscalene block (ISB) for shoulder surgery(3) but not after supraclavicular block (SCB). We present 2 cases of PPNP following US-guided SCB and shoulder surgery in the sitting position. Case 1: A 62 yo female underwent right total shoulder replacement (TSR) following a left TSR 14 weeks earlier under US-guided SCB. Her history was notable for morbid obesity (BMI 44.9). Preoperative chest x-ray (CXR) was read as poor inspiratory effort and possible left basilar atelectasis (Fig 1). Following an US guided in-plane SCB with 55mL bupivacaine 0.25% plus dexamethasone PF 4 mg using a Chiba needle, general endotracheal anesthesia was induced and the patient placed in the sitting position. Upon extubation, the patient complained of dyspnea and was hypoxic requiring assisted mask ventilation. (ABG: pH 7.20, PCO2 68 and PO2 117). Intraoperative fluoroscopic examination revealed bilateral diminished diaphragm function on deep inspiration. Comparison of the 2 preoperative CXRs (Fig 1) and (Fig 2) revealed a new contralateral (left) hemidiaphragmatic elevation. Postoperatively the patient required BiPAP for >24 hours. In retrospect, the patient had dyspnea and shortness of breath following her prior surgical procedure. [Figure 1 - Preoperative CXR] [Figure 2 - CXR from Previous Admission] Case 2: A 59 yo male underwent arthroscopic right shoulder surgery in the sitting position. An US guided SCB was performed with an in-plane Chiba needle using 50mL of mepivacaine 1.5% and 10mL of bupivacaine 0.5% plus epinephrine 1:500,000. The patient was discharged home the same day. Several days later, he noted dyspnea while lying down to sleep and with normal activities. CXR revealed an elevated right hemidiaphragm. Following pulmonary function tests, a diagnosis of phrenic nerve paresis was made. MRI revealed multilevel C-Spine pathology. Discussion: We reported the incidence of PPNP following ISB for shoulder surgery in the sitting position as 1/2069.(3) It is possible that direct needle trauma to the phrenic nerve may occur with ISB and, potentially with rare anatomical variants, also SCB (4). However, anatomically, it is unlikely that the phrenic nerve would be directly injured during SCB. We propose that positioning and stretch cause PPNP. PPNP has been reported following minor cervical trauma (5), stretch injuries (6), chiropractic manipulation of the neck (7) and with C-Spine disease.(8) Brachial plexus monitoring during TSR under general anesthesia demonstrated nerve dysfunction in 57% of patients. (9) Anatomically, these cases of PPNP were likely secondary to the stretch and position and not SCB. References: 1. Urmey et al. Anesth Analg 1991;72:498-503 2. Renes et al. Reg Anesth Pain Med. 2009;34(6):595-9 3. Zayas, ASRA 2009 4. Gupta et al. J Pain, Symptom Control and Palliative Care. 2009;7(1) 5. Bell et al. J Accid Emerg Med. 2000;17(6):419-20 6. Synder et al. JTrauma. 1994;36(5):734-6 7. Merino-Ramirez et al. Muscle Nerve 2007; 36(2): 267-70 8. Li, ASRA 2011 9. Nagda et al. J Should Elb Surg 2007;16:2S-8S A203 FEMORAL NERVE CATHETER PLACEMENT FOR ACL REPAIR COMPLICATED BY A FULL THICKNESS SKIN WOUND H.J. Heyman, D.M. Hunter 1 2 Anesthesiology, Orthopaedic Surgery, Georgia Health Sciences University, Augusta, GA, USA Objective: To describe an unusual complication after femoral nerve catheter placement. A 15 yo female presented for ACL reconstruction after a ground level fall. Past medical history consisted of morbid obesity with a BMI of 46, no known allergies, previous surgeries or anesthesia. An anesthetic plan was discussed and was decided to proceed with general anesthesia combined with femoral nerve catheter for postoperative analgesia. Catheter placement was performed preoperatively under ultrasound guidance with an Arrow stimulating catheter. Placement was uneventful with quadriceps twitch obtained to a minimal current of 0.8mA, negative test dose and was bolused with 20ml of ropivacaine 0.5%. The catheter was tunneled laterally using a touhy needle and stylette and secured with mastisol and tegaderms. The tunnel site was anesthetized with a mixture of the remaining 2ml 1.5% lidocaine with 1:200,000 epinephrine from the test dose vial and another 4 ml of 1% lidocaine plain. The patient proceeded to the operating room where she underwent general anesthesia and the procedure was completed without incident. Intraoperatively the femoral catheter infusion was started with ropivacaine 0.2% at 10ml/hr. Postoperatively she complained of no pain in the post-anesthesia care unit and was transferred to the pediatric floor with the femoral nerve catheter infusion. While on the floor she continued to have no pain and remained hospitalized one night. She was to be discharged the morning after surgery and was offered an ambulatory femoral nerve infusion. She declined ambulatory infusion and the catheter was removed without difficulty. The patient reported return of normal sensation and motor strength within several hours of the infusion being stopped. She was next seen by her surgeon 6 days later and was found to be progressing normally and had no new complaints. She was seen the following day by physical therapy who noted a 5cm x 4cm full thickness skin wound at her upper thigh in the area of the nerve block. The wound had no erythema or drainage and appeared clean. Patient stated she had noticed it just that day as it is located under a large abdominal pannus and was not visible to her and caused no pain. She was referred to plastic surgery for evaluation. The plastic surgeon recommended silvadene daily and to follow up in one week. At the one week follow up the wound appeared clean and had not progressed. She was offered excision and primary closure to accelerate healing but declined. She was recommended to continue silvadene and to return in one week, however was lost to follow up after this appointment. She continued to be seen by physical therapy and voiced no further complaints about the wound. Potential causes for the wound include unrecognized reaction to the tegaderms, mastisol or epinephrine containing lidocaine at the tunnel site, and less likely infection. Progression of the wound was likely due to the patient´s abdominal pannus covering the site impeding healing and earlier recognition by the patient herself. [Skin Wound] Personal conflicts of interest disclosure: Nothing to disclose. A204 ULTRASOUND GUIDED AIRWAY BLOCKADE FOR AWAKE FIBEROPTIC INTUBATION D. Demaculangan, J. Hedden, L. Maracaja-Neto, A. Hummel, J. Mazer Department of Anesthesiology, SUNY Health Science Center at Brooklyn, Brooklyn, NY, USA Airway preparation using nerve blockade for awake intubation is often performed using surface landmarks and palpation of underlying target structures. However, these blocks can be challenging to do in those with thick short necks or abnormal neck anatomy. Ultrasound (US) guidance is widely used in nerve block procedures, but it has rarely been used for airway blockade (Manikandan1, DeOliveira2, Green3).1,2,3 The sonoanatomy of the airway has been extensively described (Singh4, Kundra 2011,5, Kristensen6)4,5,6. These sonoanatomical descriptions can be used to facilitate the performance of airway blocks such as the superior laryngeal nerve (SLN) and translaryngeal/recurrent laryngeal nerve (TL/RLN) blocks. We present systematic technical descriptions of US guided SLN and TL/RLN blocks performed on two patients who underwent awake fiberoptic intubation (FOI). We review the techniques described in previous reports and present new alternative approaches. We also describe imaging artifacts from the air-membrane interface (AMI) present in the airways that can mislead the anesthetist if not recognized. A205 A SUCCESSFUL USE OF THE ALTERNATIVE CATHETER-OVER-NEEDLE ASSEMBLY FOR CONTINUOUS LOWER INTERSCALENE BLOCK IN DISTAL HUMERUS SURGERY AND OLECRANON SURGERY: A CASE REPORT V.H.Y. Ip, B.C.H. Tsui Department of Anesthesia and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: The interscalene blocks spares the lower trunk of the brachial plexus in approximately 1 2 half of all cases. Low interscalene single-shot blocks have been successful for elbow surgery, but there is currently no literature regarding the successful use of low interscalene catheters. Here, we demonstrate the successful use of low interscalene catheter for distal humerus and olecranon surgery using a non-traditional method to place the catheter. Consents have been obtained. Material and method: A 77-year-old female, was scheduled for open reduction and internal fixation of a comminuted fracture of the left humerus. A low interscalene catheter was inserted pre-operatively under ultrasound guidance with a 13-6 MHz high frequency linear transducer. After a local anesthetic 3 wheal was raised, a 21G x 95 mm catheter-over-needle unit was directed in-plane towards the interscalene groove, between the C5 root and the trunks of the brachial plexus. After confirming the spread of dextrose 5% in water (D5W), 25 mL of local anesthetic was injected between the sheath and the roots. The needle was withdrawn, and a flexible, 20G x 75 mm inner catheter was inserted through the 18G outer catheter and was Luer-locked in place. Under ultrasound, the spread of 5 mL of local anesthetic was observed as it was injected through the catheter (Figure-Arrows pointing at the catheter and the asterix shows the spread). [Lower interscalene catheter] Surgery proceeded uneventfully. Results: No leakage was noted at the site of the catheter insertion after either bolus, and a good sensory block was achieved. Local anesthetic infusion continued for two days, and the patient remained comfortable throughout this recovery period. The catheter was removed, and no evidence of kinking was observed. The dressing remained dry and intact at 72 hours postoperatively. Subsequently, we performed a similar procedure with similar successful results on a patient who underwent open reduction and internal fixation of the right olecranon. Discussion: Our preliminary results from these two cases demonstrate the successful use of the alternative catheter-over-needle assembly to provide continuous low interscalene nerve block for distal humerus surgery. The catheter-over-needle assembly provides a stable, effective means of delivering a continuous interscalene block that mitigates the problems of the traditional approach. References: 1. Neal JM et al. Reg Anesth Pain Med. 2009; 34: 134-70. 2. Gadsden JC et al. J.Clin.Anesth 2009; 21: 98-102 3. Ip V et al. Can. J. Anesth. 2012; 59: 1125-9 Funding: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest: The Pajunk MultiSet 211156-40E is modified and re-designed by Ban Tsui. Dr. Tsui also has a patent-licensing agreement with Pajunk. A206 INTERCOSTAL CATHETER PLACEMENT FOR CHEST TUBE RELATED PAIN IN PATIENTS UNDERGOING PULMONARY RESECTION WITH CONTRAINDICATIONS TO EPIDURAL BLOCK J. Jackson, V. Puttanniah, A. Gulati 1 2 NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, Memorial Sloan Kettering Cancer Center, New York, NY, USA Introduction: Thoracic surgery involving the placement of a chest tube is painful, and adequate analgesia is necessary in order to maximize postoperative pulmonary function and reduce the risk of complications. While thoracic epidural analgesia is typically employed for postoperative pain management in these cases, it is not without risks and side effects. Further, some patients are ineligible for placement. We describe two cases of effective analgesia via continuous intercostal blockade in patients who were unable to undergo epidural placement. Material and methods: Two patients undergoing pulmonary resection with contraindications to epidural placement, which included anticoagulation with Plavix in the first case and the presence of an intrathecal pain pump in the second case, underwent ultrasound-guided intercostal nerve blockade and catheter insertion at the level of chest tube placement at the end of surgery. Patients were initially given an 8-10 mL bolus of ropivacaine 0.2% during placement, and subsequently ropivacaine 0.10.2% was infused at 5mL/hr until the chest tube was removed. Supplemental analgesia was provided with intravenous patient controlled analgesia (IVPCA) and ketorolac. The patients were then evaluated for postoperative pain control, side effects, and any complications daily by the pain service until the catheter was discontinued. Results: Intercostal blockade was highly effective in both patients in terms of postoperative pain control and preservation of pulmonary function. Both patients rated their pain as acceptable throughout the entire duration of follow-up, with pain scores ranging from 2-6 on a 10-point scale in the first patient and from 4-5 in the second patient. IVPCA usage ranged from 1.2-3.4 mg of morphine equivalents per hour. No complications from catheter placement were observed. Side effects were minimal and primarily consisted of nausea in one patient attributed to intravenous opioids. Discussion: These cases suggest that intercostal nerve blockade via a continuous infusion of local anesthetic is a safe and effective alternative for management of chest tube related pain in patients undergoing pulmonary resection with a contraindication to epidural placement. References: Concha M, Dagnino J, Cariaga M, Aguilera J, Aparicio R, Guerrero M. Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine. J Cardiothorac Vasc Anesth 2004;18(3):322-6. Detterbeck F. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005;80:1550-9. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, Neugebauer EAM, Rawal N, Schug S, Simanski C, Kehlet H. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026-40.Kaiser A, Zollinger A, De Lorenzi D, Largiader F, Weder W. Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain. Ann Thorac Surg 1998;66:367-72. Katayama T, Hirai S, Kobayashi R, Hamaishi M, Okada T, Mitsui N. Safety of paravertebral block in patients ineligible for epidural block undergoing pulmonary resection. Gen Thorac Cardiovasc Surg 2012;60:811-14. Takamori S, Yoshida S, Hayashi A, Matsuo T, Masahiro M, Shirouzu K. Intraoperative intercostal nerve blockade for postthoracotomy pain. Ann Thorac Surg 2002;74:338-41. Funding: Nothing to disclose Personal conflicts of interest disclosure: Nothing to disclose A207 SUCCESSFUL ADDUCTOR CANAL CATHETER AND POSTERIOR TIBIAL NERVE BLOCK FOR A PATIENT WITH ACHONDROPLASTIC DWARFISM FOR TOTAL KNEE REPLACEMENT M. Jacobson, M. Tu, B. Kosharskyy, N. Shaparin, K. Gritsenko Anesthesiology, Montefiore Medical Center - Albert Einstein College of Medicine, Bronx, NY, USA Introduction: The most commonly dwarfism, achondroplastic, occurs in 1:15-40,000 births annually (1). Associated findings include airway abnormalities, sleep apnea, thoracic kyphosis, and scoliosis, (1) yet Pubmed analysis shows no data regarding regional anesthesia techniques for lower extremity orthopedic procedures. Case: A 4´3 130lb woman presented for knee replacement. Leg length measured 64 cm from anterior superior iliac spine to lateral malleolus. An adductor canal catheter and tibial nerve block was planned. Under ultrasound guidance, an 18 gauge 2 inch Tuohy needle was advanced in-plane toward the adductor canal; 20mL of 0.5% Ropivacaine and 4 mg dexamethasone was injected. Catheter was positioned through the tuohy and secured. The knee was repositioned in 30 degree flexion and tibial nerve was identified at the popliteal groove. A 90mm, 21 gauge needle was advanced medially inplane with peripheral nerve stimulation; 10mL of 0.5% Ropivacaine and 4mg of dexamethasone was injected. Anesthetic was discussed preoperatively; as catheter in mid-thigh allowed only 11 cm between insertion site and lateral aspect of the knee, limiting surgical field. The surgeon placed the tourniquet immediately on the adductor canal catheter while monitoring for kinking or dislodgement. Surgery was performed under general anesthesia. Peripheral catheter infusion was initiated postoperatively using 0.2% Ropivacaine continuously at 6ml/hr for 2 days. The patient reported excellent analgesia in the first 24 postoperative hours; 5mg in PACU and 4mg via IV PCA. On POD#2, she required 52mg of IV Morphine via PCA, which may have been related to catheter movement or posterior knee pain from resolved tibial blockade. Patient was discharged on POD#3. The orthopaedic surgeon confirmed excellent patient satisfaction at 1 week follow-up. [Posterior Tibial Block] [Adductor Canal Block] Conclusion: Documented quadriceps weakness and falls in patients receiving femoral nerve blocks/catheters for total knee replacements led to newly popular and successful adductor canal blocks/catheters targeting the saphenous nerve to be used in the adult population (2). Catheters placed into the adductor canal can infuse local anesthetic, reducing pain scores, increasing time to requiring breakthrough pain medication, allowing earlier ambulation, and reliably provide knee pain relief postoperatively (3,4). In combination, adductor canal and tibial blocks can allow for superior analgesia (3,4). This case report indicates excellent postoperative pain control in a patient with altered anatomy. References: 1. Monedero, P., et al., Is Management of Anesthesia in Achondroplastic Dwarfs Really a Challenge? Journal of Clinical Anesthesia. 9:208-212, 1997. 2. Jenstrup, M.T., Jaeger, P., Lund, J., Fomsgaard, J.S., Bache, S., Mathiesen, O., Larsen, T.K., and Dahl, J.B., Effects of Adductor-Canal-Blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anesthesioogica Scandanavica. 56: 357-364. 2012. 3. Anderson, H., Gyrn, J., Moller, L., Christensen, B., and Zaric, D., Continuous Saphenous Nerve Block as Supplement to Single-Dose Local Infiltration Analgesia for Postoperative Pain Management after Total Knee Arthroplasty. Regional Anesthesia and Pain Medicine. October, 2012. 4. Kapoor, R., Adhikary, S.D., Siefring, C., and McQuillan, P.M., The saphenous nerve and its relationship to the nerve to the vastus medialis in and around the adductor canal: an anatomical study. Acta Anesthesiologica Scandanavia. 56: 365-367. 2012. A208 MANAGEMENT OF UNREMITTING SICKLE CELL PAIN IN A DIFFICULT PATIENT A. Kalava, S. Jafari, J.M. Yarmush, J. SchianodiCola New York Methodist Hospital, Brooklyn, NY, USA Introduction: Pain during sickle cell crisis is an emergency. Hydration, anti-inflammatory drugs, aggressive analgesia, and possibly vasodilators could abort the crisis and prevent or minimize further damage. Relative opiate tolerance, allergies to opiates and patient refusal to traditional therapy makes pain control in these patients extremely difficult. We present a case of a 21 yr old who had minimal pain relief with intravenous ketamine and underwent exchange transfusion as a last resort with good result. Case report: 21 year old male, with sickle cell disease, prior history of acute chest syndrome, recurrent priapism, hypertension, s/p bilateral hip replacement, presented with generalized pain in the muscles, back, thigh and chest. He also reported priapism which lasted 5 hours the night before presentation. He was oxycodone dependent with daily dose requirements of up to 30mg every 4hours. He ran out of oxycodone, after which the symptoms began. He also reported major allergy to hydromorphone. Laboratory data ruled out sepsis, acute chest syndrome and aplastic crisis. His penis was flaccid. On admission, he was started on oxygen, IV hydration, NSAID's and IV morphine and methocarbamol, hydroxyurea and folic acid. On day 2 of admission, pain management was consulted as he had recurrence of priapism and as he complained of intolerable pain. Urologists administered intracavernous dose of 1 ml of 1% phenylephrine with good detumicense and the patient was started on morphine patient controlled analgesia (PCA) at a basal rate of 0 mg, patient bolus 2 mg every 8 minutes after a load dose of 5 mg, along with oxycodone (controlled release) 30mg every 4 hours. Over the next few days patient needed escalating doses of morphine PCA reaching a basal rate of 2mg, bolus of 4.5mg every 8 minutes by day 5. On day 6, patient had a recurrence of priapism with spontaneous resolution and reported generalized intolerable pain with the analgesic regimen he was on. Treatment options of epidural analgesia, nerve blocks, change of opioids both the IV form and the oral form, adding the adjuvant meds, were all refused by the patient. After a long debate, patient consented to try IV ketamine in addition to morphine PCA, which was started at 7mg/hour and titrated up to 12 mg/hour in less than 24 hours. Following ketamine infusion patient continued to complain of moderately severe pain at which point exchange transfusion was considered. Exchange transfusion was performed on day 8 with good pain relief. Ketamine infusion was slowly tapered and stopped on day 11. Patient was transitioned to methadone 20mg once daily, gabapentin 300mg Q8hourly and low dose morphine PCA at this time. He is slated for a discharge soon. Discussion: Traditionally exchange transfusion in sickle cell is reserved for acute stroke, acute chest syndrome with severe hypoxia, acute multi-organ failure, and possibly acute severe priapism. In patients who fail to respond to traditional analgesic treatment with opiates and low dose infusions of ketamine, exchange transfusion can be tried as a last resort. A209 REDUCTION OF HIP DISLOCATION WITH FASCIA ILIACA COMPARTMENT BLOCK U. Kaldirim, S.K. Tuncer, S. Bilgic, M. Yetim 1 2 Emergency Medicine, Anesthesiology, Gulhane Military Medical Academy, Ankara, Turkey Introduction: In aging societies hip fracture incidence increases. Trochanteric fractures account about half of all hip fractures in geriatric people. Reduction and pain control in patients with hip dislocation is quite difficult. Pain management with drugs may cause a large variety of deleterious side effects especially in aged. Method of choice includes Fascia iliaca compartment block in femur fractures (1). In this report, we describe a 65-year- old woman who presented with right hip pain and limping as a result of trauma had fascia iliaca compartment block (FICB). Case: 65-year-old female with right hip pain and limping as a result of a low energy trauma was admitted to emergency department. Her past medical history revealed arterial hypertension, chronic obstructive lung disease and surgery of total right hip with internal fixation. Sensorial, motor and peripheral arterial examination of right limb was otherwise non-contributory. Radiologic assay revealed dislocation of right limp with internal fixation. Reduction was unsuccessful in first attempt. For pain control and ease of reduction, ultrasound guided FICB was decided to perform when effects and her comorbidity were taken into consideration. Her vital signs were in normal range except oxygen saturation of 88 % on room air.at a time (Figure). Totally 30cc of medicine including 5cc of normal Saline, 15cc of 0.5% Bupivacaine and 10cc of 1% Lidocaine were administered on site of fascia iliaca compartment. After providing adequate anesthesia; reduction was successfully performed at a time with Allis´s maneuver. Patient was hospitalized in orthopedic service for further examination. Discussion: Although hip dislocation is not so common in patients with internal fixation; it is one of the reasons of admittance to Emergency Department. In the treatment of patients with no other clinical findings suggestive of fracture or corruption in internal fixator, reduction is adequate. Reduction is a painful and difficult procedure. Analgesia even sometimes procedural sedation is advised to promote successful manual reduction. Method of choice includes Fascia iliaca compartment block in femur fractures (1, 2). Peripheral nerve blockade is advised to be performed with sonographic guidance in order to perform in ease and safety (3). In our case we preferred ultrasound guided FICB. reduction was incredibly easy and free of pain. Hip dislocation with or without fractures managed with FICB will ease the management of dislocation. References: 1. Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med. 2011 Dec;18(6):340-3.( PMID: 21422933) 2. Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med. 2007 Aug;50(2):162-71. (PMID: 17210208) 3. Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, Likourezos A. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med. 2012 Oct;43(4):692-7 (PMID: 22494596) A210 AN UNUSUAL CASE OF ASIA C T-10 PARAPLEGIA AFTER LUMBAR TRANSFORAMINAL EPIDURAL STEROID INJECTION H. Kalia, J. Kent Anesthesiology, University of Rochester Medical Center, Rochester, NY, USA Introduction: Epidural Steroid Injections have been used widely to manage both axial low back and radicular leg pain for more than 30 years. Fluoroscopically guided epidural injections carry an overall 1 complication rate of 0% - 9.6%. Although Paraplegia following a transforaminal injection is extremely rare; it has been reported in the literature. Case description: Mrs.S is a 59 y/o F with past medical history significant for SVT,depression, hypothyroid, GERD, undifferentiated connective tissue disorder, renal cell carcinoma status post left partial nephrectomy in 2010 and Significant spinal stenosis. Her baseline segmental pathology as elucidated through an MRI is as follows: 1) Moderate Right L1-2 foraminal stenosis 2) 5mm synovial cyst at left L1-2 facet joint 3)Mod Right L2-3 foraminal stenosis. 4) Severe right L3-4 foraminal stenosis with facet arthropathy. 5) Diffuse disc osteophyte complex abutting left L5 & L4 nerve root. 6) Severe Left and moderate right L4 foraminal stenosis. 7) Severe Left L5 foraminal stenosis. 8) Scoliosis. Patient was scheduled for Left L4 and L5 transforaminal steroid injections due to her predominant radicular leg pain along the Left L4/ L5 dermatomal distribution. 6ml”s of 1% lidocaine was used to infiltrate the skin. A 22-gauge 5 inch spinal needle was advanced into the cephalad aspect of the “safe triangle”. Both roots were targeted lateral and caudal to the standard approach due to significant osteophytes. After the needle tip was confirmed on both AP and lateral images; and, aspirate was negative for CSF and heme; 3ml Omnipaque 240mg/ml was used to ascertain the placement. There was no vascular or intrathecal spread of contrast. 50 mg of methylprednisone acetate and 1 mL of 1% lidocaine was injected at each level. Patient instantaneously developed paraplegia following the injections. Her initial examination was consistent with ASIA-C T-10 paraplegia. MRI with contrast within 24hrs and 48hrs were negative for any ischemic cord injury or subdural hematoma. Patient recuperated most of her motor and sensory deficits on the right side over the course of next 48hrs but her recovery pattern on the right side remained protracted. She continued to make neurological and functional gains over the next 14 days. Discussion: There are total 12 cases of paraplegia reported in literature following an epidural steroid injection. We hereby report the only case of transient paraplegia which resolved over the course of 15 days. Interestingly, the only minor deficits which prevail in our patient are motor strength 4/5 in Left Hip flexors and diminished pin prick and light touch below Left L4 dermatome. Patient”s clinical presentation and recovery pattern fail to justify any particular theoretical explanation. Her recovery pattern precludes a possibility of intrathecal or subdural injection. A plausible explanation ranges from vascular spasm, intravascular injury to a possibility of “double crush syndrome” where- in her baseline significant spinal pathology predisposed her to develop spinal cord injury following an epidural injection. Reference: 1. Houten, J. K., & Errico, T. J. (2002). Paraplegia after lumbosacral nerve root block: Report of three cases. The Spine Journal, 2(1), 70-75. A211 SACRAL AND THORACIC NERVE STIMULATION FOR A COMBINED EFFECTIVENESS ON THE TREATMENT FOR CHRONIC TESTICULAR PAIN S.S.W. Kim, T. Edala, M. Patel, A. Ghaleb Anesthesiolgy, University of Arkansas for Medical Sciences, Little Rock, AR, USA Chronic testicular pain is becoming a more common problem. Due to the numerous potential etiologies, it can often be frustrating and time consuming to both the physician and the patient. One of the more common causes of chronic testicular pain is post vasectomy pain which has been reported to range from 15-19% but may be up to 52%. Recently there has been increased interest in spinal cord stimulation as an alternative treatment for chronic testicular pain. Previous case reports of nerve stimulations of both the sacral nerves and of the dorsal columns of the thoracic nerves has given promising results. McJunkin et al. has described testicular pain reduction of 80% with sacral nerve stimulation and Nouri et al. reported a reduction of VAS scale score from 5/10 to 1/10. However, in our case we were able to look at both sacral and thoracic stimulations independently and as a combined effect. Because we implanted two separate leads, our patient was able to independently control stimulations in both areas. He reported that although separate lead stimulation produced relief, it was the combined effect that gave him the greatest reduction to pain of at least 75%. Due complex and significant overlap of the innervations of the scrotal content we were able to demonstrate that the combined effects of SCS on both lumbar and sacral nerves may provide better relief in patients refractory to SCS of either lumbar or sacral nerves. A212 DELAYED ONSET OF SYMPTOMATIC PHRENIC NERVE BLOCK AFTER INTERSCALENE BRACHIAL PLEXUS BLOCK IN A MIDDLE-AGED PATIENT K. Candido, Y. Slota, N.N. Knezevic 1 2 Anesthesiology and Pain Medicine, Advocate Illinois Masonic Medical Center, Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Introduction: The incidence of phrenic nerve blockade following interscalene brachial plexus block approaches 100% unless very modest of local anesthetics are injected using ultrasound guidance. However, the majority of patients remain asymptomatic by recruiting accessory respiratory and 1 abdominal muscles. The onset of symptoms generally correlates with the pharmacological properties of the local anesthetic used for the block. We report a case of a symptomatic phrenic nerve blockade developing five hours after the onset of the sensory nerve blockade in a 42 year-old patient undergoing elective shoulder surgery under combined regional block-general anesthesia. Case description: A 42 year-old male patient with a history of multiple right shoulder surgeries and 2 BMI of 33 kg/m presenting with right shoulder impingement syndrome was scheduled for right shoulder arthroscopy and open acromioplasty. The patient was consented for right interscalene brachial plexus block for post operative analgesia, and surgery was performed under general anesthesia. Ultrasound was used to locate the proximal trunks of the plexus. At a depth of 1.5 cm, a 0.4 mA deltoid twitch was elicited and 30 mL of 0.5% ropivacaine was incrementally injected in the preoperative nerve block area. Complete sensory block was successfully obtained after 30 minutes and the patient denied respiratory symptoms. The baseline SpO2 did not decrease from 98% in the first 45 minutes following block completion. The respiratory rate varied between 14 and 18 breaths/minute during this time period. The patient was taken to the OR and general anesthesia was induced without complications. Only 50 mcg of fentanyl were used as adjuncts to anesthesia and the trachea was extubated after full reversal of muscle relaxants at the completion of the 1.6 hour surgery. The patient remained pain free and asymptomatic in the PACU, and he was transferred to the floor. The patient complained of chest discomfort and dyspnea, five hours post block. The S pO2 on room air was noted to be 92% and the respiratory rate was 26/minute. Cardiac and pulmonary workup did not reveal any abnormalities. A chest X-ray demonstrated evidence of right diaphragmatic hemiparesis consistent with unilateral, ipsilateral right phrenic nerve blockade. [Figure 1] The patient was reassured and kept on supplemental oxygen throughout the night. The following morning, the phrenic nerve block resolved and the dyspnea was eliminated. Conclusion: Respiratory symptoms related to phrenic nerve blockade are usually expected to correlate with motor block onset. In 2006, Delcourt et al. reported three cases of delayed respiratory symptoms in geriatric patients after nerve-stimulator ISB with approximate onset of 2-3 hours after 2 block completion. This case report is unique in that the onset was 5 hours after ultrasound ISB in a middle-aged patient. This report should raise awareness of the possibility of delayed respiratory symptoms in virtually any patient being provided an ISB using volumes conventionally employed in common clinical practice. References: 1. Verelst, P. et al. Reg Anesth Pain Med 2011;36:411-2. 2. Delcourt, J. et al. Can J Anaesth 2006;53:110-1. A213 INCIDENTAL FINDING OF A HEMATOMA DURING FEMORAL NERVE BLOCK S.H.P. Kolli, H.K.P. Kalagara, K. Maheshwari, E. Farag, M.L. Soliman Anesthesiology, Cleveland Clinic, Cleveland, OH, USA Objective: To report a case of inguinal hematoma complicating the anatomy and performance of a femoral nerve block. Case report: A 64 year old lady scheduled for total knee arthroplasty was consented for a continuous femoral nerve block for post-operative pain relief. On ultrasound examination the anatomy was distorted due to the presence of a large hypo-echoic structure medial to the nerve with a very small artery. Discussion: Ultrasound guidance for regional anesthesia is an evolving field. With the increased use of this technology by our community, atypical and even pathologic anatomy may be revealed. Conclusion: The Ultrasound was useful not only to identify but avoid the hematoma while performing the block. We can expect to come across more similar situations given the increased use of ultrasound. Hence this reemphasizes the need for the training in ultrasound to incorporate the ability to appreciate the common non neural pathology. A214 CONTINUOUS INTERSCALENE NERVE BLOCK FOR PALLIATIVE MANAGEMENT OF INTRACTABLE PAIN FROM BRACHIAL PLEXOPATHY ASSOCIATED WITH PANCOAST TUMOR M. Koski, K. Maheshwari, W. Ali Sakr Esa, A. Rao 1 2 General Anesthesia, Palliative Medicine and Supportive Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA Introduction: The incidence of painful brachial plexopathy in all cancer patients is 0.4%. It is often difficult to treat with conventional analgesics including opioids which offer suboptimal relief .We report a patient with intractable brachial plexopathy successfully managed with an interscalene peripheral nerve block in hospice reducing the need for recurrent admissions for pain control. Patient History: A 41 yr old female presented with left upper extremity pain radiating to the axilla and no Horner´s syndrome. A superior sulcus cancer (Pancoast tumor) arose from her left upper lobe. Her pain was managed with a combination of hydromorphone and methadone, amitriptyline and naproxen which were continuously titrated up over 2 months with minimal relief. She subsequently underwent a left upper lobectomy with en bloc resection of ribs 1 through 4, mediastinal lymphadenectomy and chest wall reconstruction. She was deemed hospice appropriate. Over a few months she was admitted on 4 occasions with severe pain. Cryoablation, high dose hydromorphone PCA, ethosuximide, ketamine and palliative sedation were attempted without success. An interscalene peripheral nerve catheter was inserted subsequently with continuous infusion of ropivacaine 0.2% at a basal rate of 10ml/hr and 10 ml demand dose every 60 min and following this patient´s pain was better controlled (decreased from severe to mild). Hydromorphone dose in the PCA was decreased significantly and she was able to be weaned from methadone. She did not need readmission. Discussion: Continuous nerve blocks relieve brachial plexopathy pain in lung cancer. Regional blocks are preferable to destructive procedures such as cordotomy and decrease the need for opioids. Multiple reasons like cost, awareness among providers , infection risk with prolonged block, lack of specialised team for performing blocks and follow up may present as barrier leading to underuitilization of regional nerve blocks while in hospice. These challenges for considering regional blocks needs to be weighed against suboptimal pain control and readmissions . Conclusion: Interscalene regional blocks reduce refractory brachial plexopathy pain and should be considered as an option for pain management. References: Buchanan, D etal. Outpatient Continuous Interscalene Brachial Plexus Block in CancerRelated Pain. Journal of Pain and Symptom ManagementVolume 38, issue 4, p. 629-634. October, 2009. [MRI C spine. Paraspinal mass on the left extending] A215 PULMONARY HYPERTENSION DURING PREGNANCY: A CASE PATIENT MANAGED WITH AN INTRATHECAL BUPIVACAINE INFUSION FOR CESAREAN SECTION J. Kwan, D. Nguyen, C. Martinello, A. Singal, A. Van, E. Hurwitz Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA Pulmonary hypertension in pregnancy, a relatively uncommon condition, is associated with significant morbidity and mortality for the parturient. The physiologic changes of normal pregnancy may include abrupt fluid shifts and considerable increases in cardiac output and plasma volume with reduction of systemic vascular resistance. While these demands are usually well tolerated by the otherwise healthy parturient, pulmonary hypertension in the setting of pregnancy places the patient at significant risk for life-threatening right ventricular failure and hemodynamic collapse. Planning and vigilant management of this condition is of particular importance during parturition and the postpartum period. We present a case of a 37-year-old term pregnant African American woman with severe pulmonary hypertension based on right ventricular systolic pressure exceeding 60 mm Hg on transthoracic echocardiography. A right heart catheterization confirmed the findings on echocardiography. Her additional comorbidities include moderate mitral stenosis with regurgitation, diabetes mellitus type II, history of rheumatic heart disease, morbid obesity with a BMI greater than 45, and three previous cesarean sections. The patient reported occasional clinically significant dyspnea during pregnancy and also with exertion. The anesthesiology service had decided on specific monitoring and interventions for the day of the planned cesarean section. Our management for the patient included an arterial catheter placed prior to the procedure for hemodynamic monitoring in addition to standard monitors. Based on a literature review conducted by our team, the use of pulmonary artery catheterization is generally used on a case-by-case basis. After extensive discussion between multiple specialties including cardiology, pulmonology, obstetric maternal-fetal medicine, and anesthesiology, it was ultimately determined that an intraoperative pulmonary artery catheter may not improve diagnostic value based on her known symptoms. Additional preparation included having a fluid warmer with a rapid infusion setup and blood products immediately available in the room. In our case patient, we also utilized phenylephrine, albumin, and blood transfusions as clinically indicated by vital signs and clinical symptoms. Other pharmacological agents immediately available were milrinone, sildenafil, dobutamine, epinephrine, and epoprostenol. Our initial analgesic management for the scheduled cesarean section planned for an epidural catheter with slow titration to an appropriate level of surgical anesthesia. During attempted epidural catheter placement by another anesthesiologist, an unintentional dural puncture occurred, which was confirmed with cerebrospinal fluid return. Consequently, an intrathecal catheter was utilized instead. The patient was managed with an intermittent intrathecal titration of hyperbaric 0.75% bupivacaine and preservative-free morphine and did not suffer any complications intraoperatively. Postoperatively, blood transfusions with appropriate fluid resuscitation were administered via a right internal jugular central venous catheter and titrated to clinical symptoms and response. The patient recovered well and was ultimately discharged four days post-procedure. Pulmonary hypertension during pregnancy is a rare condition that can be associated with significant morbidity and mortality. Treatment often requires individualization for each patient presentation. Further research on parturients with pulmonary hypertension will likely be beneficial to determine optimal treatment algorithms that also include neuraxial anesthesia and analgesia for this patient population. A216 EPIDURAL ANESTHESIA FOR THE TREATMENT OF LOWER EXTREMITY ISCHEMIA FOLLOWING AORTIC ENDOVASCULAR SURGERY: A CASE REPORT L. Lahaye Virginia Commonwealth University, Richmond, VA, USA Introduction: Management of lower limb ischemia in the setting of recent aortic endograft placement is dictated by the inciting factors. We present a case of lower extremity arterial insufficiency following endovascular aortic repair that resolved with the induction of regional anesthesia with epidural local anesthetic. Case report: A 60 year old female with a medical history significant for hypertension, COPD, chronic pain and tobacco abuse was transferred to our hospital with radiographic findings of a contained rupture of her abdominal aorta. The patient had a two day history of severe abdominal and back pain and a CT study demonstrated involvement of the infrarenal abdominal aorta. On the morning of surgery, a thoracic epidural catheter was placed in the pre-operative holding area however was not used during case at the request of the surgeon in favor of a general technique. The aorta was accessed via bilateral groin sheaths. Two grafts were deployed, one extending from the distal margin of the left renal artery and a second intussuscepted within the first to the aortic bifurcation. Completion angiography demonstrated preservation of both common iliac and renal arteries as well as complete exclusion of the aorta proper. Post-operatively the patient was admitted to the Intensive Care Unit with the epidural catheter in situ without infusion. All distal pulses were confirmed intact by bedside Doppler. Thirty minutes later the patient complained of left lower extremity pain and coolness and was found to have a mottled limb below the knee with Doppler signals lacking distal to the femoral artery. Vascular access sites appeared externally normal. Formal duplex and color flow ultrasound studies demonstrated monophasic waveforms distal to the external iliac artery suggesting a proximal obstruction. The patient was transported to the holding area in anticipation of urgent angiography and thrombectomy. At that time the patient's epidural was bolused with 2% lidocaine to achieve a T10 level of anesthesia after which she was transferred to the operating room. Upon arrival, the patient was re-evaluated and found to have palpable femoral, popliteal and posterior tibial pulses which were conformed present with Doppler. Discussion: Epidural sympatholysis has been described as part of multi-modal treatment for patients with severe, limb threatening lower extremity ergotamine induced vasospasm (1). Continuous sympathetic blockade with epidural analgesia has also proven beneficial in severe cold injury of the lower extremities. Other forms of sympatholysis have been used for patients with vasospastic pathology including Raynaud's disease (2). Given the rapid reversal of our patient´s arterial insufficiency following epidural induction, the diagnosis of thrombotic or embolic occlusion was unlikely. Epidural anesthesia may be considered in treating lower extremity vasospasm following major vascular surgery. References: 1. Demir, S et al. Diagnostic Interventional Radiology 2010; 16: 165-167 2. Rizzo, M et al. Orthopedics 2004; 27(1): 49-52 A217 ASSESSING PERIPHERAL NERVE CATHETER PLACEMENT THROUGH THE USE OF ULTRASOUND COLOR FLOW DOPPLER A. Lange, E. Joe Anesthesiology, University of Maryland, Baltimore, MD, USA Introduction: Many patients benefit from continuous peripheral nerve blockade (CPNB) due to prolongation of the benefits of regional anesthesia beyond the maximum duration of a single injection. For CPNB to be effective, the catheter must be appropriately positioned. Ultrasound visualization of the catheter itself is often challenging. Several methods have been described to verify the position of the catheter indirectly, including direct ultrasound visualization of injectate spread, use of agitated contrast, and looking for tissue movement upon insertion. While useful, none are capable of identifying the catheter position with 100% success. Thus, we present an additional method that is easy, time-efficient, and safe. We report a case where ultrasound Doppler flow was used to accurately visualize the anatomic position of drug delivery and verify proper positioning of the perineural catheter when other modalities failed. Methods: This report involves a 53-year-old scheduled for rotator cuff repair under interscalene blockade. A 12L probe was used for visualization, and an 18 gauge Tuohy was positioned just posterior to the brachial plexus. 20mL of ropiviciane was injected incrementally to facilitate onset, and was seen to appropriately surround the plexus. A 20 gauge catheter was easily inserted through the Tuohy. Tissue movement during catheter placement under ultrasound suggested an appropriate catheter placement. However, the actual catheter tip position was unclear. Additional anesthetic was injected, but accumulation was difficult to detect. Injection of an agitated solution was also ineffective at providing satisfactory confirmation. Colorflow Doppler was then applied to the area, and the catheter was injected in a pulse-like pattern. Doppler activity confirmed injectate appropriately surrounding the brachial plexus (Figure 1). [Figure 1] Results: The patient achieved excellent sensory and motor blockade. He was taken immediately to the operating room and underwent surgery under interscalene block with IV sedation. The patient denied any pain in the PACU and had an uneventful discharge home with an infusion pump. The patient was contacted via phone, and he reported continued excellent pain relief and sensory blockade in his shoulder. Infusion was completed by POD 3 and the catheter was removed by the patient without complications. Discussion: Detection of the final position of a peripheral nerve catheter is sometimes challenging due to small injectate volumes, high catheter resistance, previously-injected solution, and difficulty visualizing the catheter itself. The use of ultrasound-guided colorflow Doppler as an additional tool to assess the spread of anesthetic via peripheral nerve catheter was valuable in this case where spread of the anesthetic was otherwise hard to visualize. This prevented the repositioning or replacement of a catheter that was in the appropriate position. This report suggests that the use of ultrasound colorflow Doppler may be a valuable tool in detecting the placement of a peripheral nerve catheter. There is no additional risk to the patient and the technique requires minimal additional time. References: Richman JM, et al. Does CPNB provide superior pain control to opioids? A meta-analysis. AnaesthAnalg2006;102(1):248-57 Ilfeld BM. CPNBs: a review of the published evidence. AnesthAnalg2011;113:904-25 A218 LOCAL ANESTHETIC SYSTEMIC TOXICITY (LAST) IN AN ESKD PATIENT UPON RECEIVING AN AXILLARY BRACHIAL PLEXUS BLOCK ALONG WITH BLOCKS OF THE MUSCULOCUTANEOUS & INTERCOSTOBRACHIAL NERVES J. Li, R. Wardhan Anesthesiology, Yale University, New Haven, CT, USA In ASA closed claim cases, LAST accounts for 1/3 of deaths or brain damage associated with regional anesthesia, 93 events have been published in past 30 years. We report a case, where a mixed ropivacaine and lidocaine solution caused CNS depression, with further progression interrupted by the administration of Intralipid. A 57-year-old African woman was scheduled for placement of an upper arm AV fistula. Patient's past medical history was significant for End Stage kidney disease, HIV on HAART, HCV, Schizophrenia, Asthma, COPD & pulmonary fibrosis.On physical exam, patient seemed to be well optimized for surgery, had a normal BMI and lab work was reflective of her comorbidities.On arrival to the OR, the patient's oxygen saturation was 93% on 2L of oxygen by nasal cannula. Patient received 1 mg of midazolam and 50 mcg.The block was placed in the OR, under ultrasound guidance. An axillary brachial plexus block was planned in hopes of avoiding phrenic nerve palsy. A total of 30 cc of local anesthetic was used consisting of 15 cc of 0.5% Ropivacaine and 15 cc of 2% Lidocaine.An intercostobrachial nerve block was done using 5cc of 2% lidocaine. Direct needle visualization was achieved with ease and patient was cooperative during the entire procedure. It was during the local infiltration of lidocaine for intercosto brachial nerve, that patient started complaining of severe pain. Roughly two minutes later, patient became increasingly somnolent and was difficult to arouse. All the vital signs were stable, no EKG changes were noted, oxygen saturation was now noted to be a 100% without any change in FiO2. Pupils were responsive to light, but did appear to be pinpoint. The differential diagnosis at that point was oversedation vs LAST. A total of 80 mcg of Naloxone was administered but no improvement was noted. At this point ,a bolus of Intralipid 75ml was administered. Soon after completion of the bolus patient started to wake up but appeared to be confused and agitated displayed some myoclonic. Another 1mg midazolam and 30mg propofol were administered. Patient became progressively unresponsive again.Surgical procedure was cancelled and the intralipid infusion was restarted. The patient slowly regained her baseline mental status. About 2.5 hours after the nerve block was placed, patient returned to her baseline mental status and a complete neural exam was intact. An emergent CT of the head was performed to rule out any CNS events, which was later found to be normal. Discussion: Risk factors for LAST in this patient were poor functional/ASA IV status, ESKD. Although aspiration of local anesthetic was done during injection, but it has not been proven to be a 100% preventive. Even though the needle tip was visualized during the entire procedure, it's unclear, at which point, the vascular injection occurred. The symptoms of LAST can be subtle & do not always consist of seizures and /or cardiac arrhythmias. Since LAST is more common than we may think and an effective prevention is not currently available,high clinical suspicion and immediate treatment may be the key. A219 GABAPENTIN AS A CAUSE OF HEPATOTOXICITY S. Mian, H. Rana Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA The treatment of lumbar radicular pain is difficult and the effective non-surgical treatments available are limited. Previous studies have shown that gabapentin is an effective conservative therapy for both acute and chronic radicular pain secondary to lumbar degenerative disc disease. Gabapentin is considered to be a safe, cost-effective adjunct in treating neuropathic pain syndromes. We present a case of a 51 year old female with a past medical history significant for chronic low back pain, HIV, hypertension, chronic hepatitis C, and Diabetes Mellitus. In June of 2011, during a routine followup to her primary care physician, our patient complained of diffuse pruritus. She was initially given symptomatic treatment and had her labs checked. Her lab work revealed a significant transaminitis. At this time her medications included glyburide, metformin, gabapentin, baclofen, Truvada, Darunavir, aspirin, trazodone, and ritonavir. She has been on her HAART regimen for years. The gabapentin was recently added 2 months prior and titrated up to a dose of 600mg three times daily. Her initial workup included a right upper quadrant ultrasound and lab work. Her ultrasound showed no cirrhosis. Her lab work was negative for ANA, LKMI antibody, mitochondrial antibody, RF, and smooth muscle antibody. Additional workup subsequently included a liver biopsy in July of 2011. This revealed an acute inflammatory process consistent with drug-induced liver injury. Her hepatitis at this point was considered stage 1, grade 3. Her physicians then took her off of glyburide, metformin, and gabapentin with frequent lab work. Her liver enzymes slowly trended downward after these medication changes. She was seen in our clinic in November of 2012 for her chronic low back and radicular pain. Her imaging revealed lumbar degenerative disc disease, mild lumbar spinal stenosis, and S1 nerve root compression. She stated that the gabapentin helped her pain significantly in the past and her previous physicians were unsure which medication caused her transaminitis. After a thorough literature search, we decided to trial gabapentin, starting at 300mg three times daily and check her liver function enzymes in 6 weeks. No other medication changes were made during this period. Her subsequent labs revealed a transaminitis with elevation of her AST in particular. We stopped her gabapentin once again and plan on re-checking her labs in 1-2 weeks. We anticipate her liver function tests to be normalized. To the best of our knowledge this is the first reported case of gabapentin induced hepatotoxicity. Gabapentin should be added to the list of drugs capable of producing this adverse reaction. Funding: None. Competing interests: None declared. References: Tremont-Lukats IW, Megeff C, Backonja M. Anticonvulsants for neuropathic pain syndromes. Drugs 2000; 60:1029-52 Richardson CE, Williams, DW, Kingham, JG. Gabapentin induced cholestasis. BMJ. 2002; 325: 635 Hsu VD, Alemayehu S, Barry E. Gabapentin induced hepatotoxicity. Int Pharm Abstr. 1995; 32:794 Lasso-de-la-Vega MC, Zapater P, et al. Gabapentin-associated hepatotoxicity. Am J Gastroenterol. 2001, 96:3460-3462. Yildrim K, Deniz O, et al. Gabapentin monotherapy in patients with chronic radiculopathy: the efficacy and impact on life quality. J Back Musculoskelet Rehabil. 2009;22(1):17-20 A220 “HIGH-RISK OUTPATIENT SURGERY” AND THE BENEFITS OF REGIONAL ANESTHESIA, EVEN IN PATIENTS ON ANTIPLATELET THERAPY C. Moore, N. Hanson, D. Auyong Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA Introduction: Arthroscopic shoulder surgery is considered a safe outpatient procedure. However, the beach chair position in which it is performed increases risk of morbidity compared to supine positioning. Associated complications, including strokes, have been reported even in healthy patients[1]. Regional anesthesia can be beneficial by reducing opioid-related side effects postoperatively. ASRA guidelines advise withholding clopidogrel 5-7 days prior to surgery, but do not offer much guidance regarding procedures during continued antiplatelet therapy[2]. Anesthesiologists often face these situations not addressed by guidelines where they must weigh risks and benefits of performing regional anesthesia in anti-coagulated patients with multiple comorbidities. Often, this limits regional techniques to “easily compressible” or “less traumatic” techniques to avoid hematomas or vascular injury. Case: A 79-year-old male presented for outpatient arthroscopic rotator cuff repair in the beach-chair position. Pertinent medical history included hypertension, GERD, diabetes, prior TIA, and acetaminophen allergy. Blood pressure was 184/86, above his baseline systolic of 160mmHg. A recent MRI showed multiple high-grade stenoses not amenable to treatment. For this he was placed on clopidogrel, which he continued for the procedure. Due to his clopidogrel use, no pre-operative brachial plexus block was performed. After detailed risk/benefit discussion with the surgeon and patient, it was decided to proceed with general anesthesia for surgery. A radial arterial-line was placed to accurately maintain blood pressure near baseline. The case was completed without immediate complications and intravenous hydromorphone was dosed for nociception. Post-operative management: In the PACU, he complained of severe shoulder pain unresponsive to opioids and became nauseated and confused shortly after administration. Per pre-operative discussion, a “rescue” single-shot interscalene brachial plexus block was performed. During ultrasound pre-scan, the dorsal scapular artery was noted to be directly posterior to the brachial plexus and in the path of a standard in-plane posterior needle approach. Therefore, an out-of-plane approach was used to avoid any vasculature and resulted in immediate analgesia. Despite ongoing use of clopidogrel, this interscalene block allowed the patient to be sent home with superior analgesia, preventing unexpected hospital admission for intractable pain. Upon follow-up, the patient reported good analgesia for >12 hours, but noted significant discomfort from the initial opioid side effects. Discussion: With uncontrolled hypertension in the setting of prior TIA, our patient underwent surgery in the beach chair position, placing him at risk of repeat stroke. Management may have been improved by using regional anesthesia and multimodal analgesics. Though there is literature highlighting the opioid-reducing benefits of regional anesthesia, little addresses performance of regional anesthesia in the setting of antiplatelet agents. With the use of ultrasound-guided regional anesthesia, vascular structures can sometimes be identified and avoided, but in the absence of large studies on individual anticoagulants to guide us, clinical judgment on individual cases must be used. In this case, regional anesthesia allowed us to avoid an unplanned hospitalization, and could likely have prevented a prolonged PACU stay if placed pre-operatively. References: 1. Pohl and Cullen. J Clin Anes 2005; 17:463-9. 2. Horlocker et al. RAPM 2010; 35:64-101. A221 SUCCESSFUL TREATMENT OF ILIOINGUINAL NEUROPATHY AFTER ROBOTIC-ASSISTED LAPAROSCOPIC SACROCOLPOPEXY WITH ULTRASOUND-GUIDED NERVE BLOCK A.R. Moraska, S. Zaky Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA Background: Intraoperative injury to the ilioinguinal nerve is commonly described as a complication of inguinal herniorrhaphy. However, it is not typically thought of with laparoscopic gynecologic surgery. Ilioinguinal nerve block, with or without ultrasound guidance, has well documented success in alleviating ilioinguinal neuropathic pain (1, 3). The following case describes ilioinguinal neuropathy after robotic-assisted laparoscopic sacrocolpopexy, for which a single shot ilioinguinal nerve block provided lasting pain relief. Case: A 45 year-old woman, with a history of hypertension, gastric bypass, and L5 disc herniation, underwent robotic-assisted laparoscopic sacrocolpopexy for vaginal prolapse. Three robotic ports were placed: above the umbilicus, and 10cm lateral to midline in the LLQ and RLQ. Surgery was uneventful. Immediate post-operative pain was managed with a fentanyl PCA and ketorolac. She was discharged home on POD #1. On POD #4, she called complaining of pain that was “constant, sharp and burning in nature, worse with movement, like barbed wire being pulled through her skin” from her right side, under the RLQ port incision, to her pubis. The pain continued to worsen. On POD #5 she presented to the ED and was admitted for pain control. Initial trigger point injection with bupivacaine and triamcinolone provided only mild, transient pain relief. Anesthesia Acute Pain Management Service was consulted and performed an ultrasoundguided single shot ilioinguinal nerve block with 20 mL 0.75% ropivacaine and 6 mg dexamethasone (images below). The patient experienced immediate and complete pain relief. She was discharged home and at 2-week and 1-month follow-up, she reported no pain at rest and only mild, intermittent discomfort with movement. [Ultrasound image, ilioinguinal nerve before block.] [Ultrasound image, after injection of ropivacaine.] Discussion: Ilioinguinal neuropathy after laparoscopic gynecologic surgery may be more common than thought. A recent study showed 2% of 317 cases from 2008-2011 resulted in significant ilioinguinal/iliohypogastric neuropathic pain requiring treatment (2). All cases with nerve injury had fascial closure of the laparoscopic port site, suggesting surgical technique plays an important role. Regardless, this case highlights the benefit of early intervention with regional anesthesia for acute postoperative neuralgia. Unfortunately, these highly effective techniques are often used only after parenteral and oral analgesics, which carry greater side effect profiles, have failed or when the pain becomes chronic. Earlier treatment with nerve blocks in these patients could lead to not only improved patient satisfaction and quality of life, but may also decrease progression to chronic neuralgia. References: 1. Finnerty O, et al. Trunk blocks for abdominal surgery. Apr 2010. Anaesthesia; 65 Suppl 1:76-83. 2. Shin JH and Howard FM. Abdominal wall nerve injury during laparoscopic gynecologic surgery: incidence, risk factors, and treatment outcomes. Jul-Aug 2012. J Minim Invasive Gynecol; 19(4):44853. 3. Thomassen I, et al. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair. Sep 27, 2012. Hernia. Epub. Funding: none. Conflict of interest: none. A222 SUPRASCAPULAR PERINEURAL CATHETER FOR POST-OPERATIVE SHOULDER ANALGESIA M. Moretto, D. Auyong Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA A 43 year old 133 kilogram male was scheduled for left arthroscopic open rotator cuff repair and distal 2 clavicle resection. Comorbidities included obstructive sleep apnea, active smoker, BMI of 42 kg/m , and chronic opioid use. A similar procedure was performed on his right shoulder two years earlier. Prior anesthetic management included a general anesthetic with interscalene block. In the PACU, the patient had dyspnea, diminished ipsilateral breath sounds, and desaturations to the 80's. He was eventually stabilized and discharged home, but then readmitted to the hospital later that evening for hypoxia and aspiration pneumonia. The patient recovered from his post-operative complications. With knowledge of prior difficulty, we performed a suprascapular perineural catheter for his current surgery. The suprascapular nerve was identified exiting from the superior trunk of the brachial plexus. A perineural catheter was placed under ultrasound guidance next to the suprascapular nerve. Fifteen milliliters of lidocaine 1.5% was dosed through the catheter. Thirty minutes later, no symptoms of dyspnea were noted and an infusion of 6 mL/hr of ropivacaine 0.2% was started. The surgery was completed under general anesthesia without complication. In the PACU, the patient reported good analgesia with no opioid requirement. SpO2 remained >97% and the patient was discharged home one-hour post operatively with the suprascapular perineural catheter. On post-operative follow-up, the patient reported excellent analgesia with subjective pain scores < 2 /10 with no dyspnea or other complaints. The catheter was discontinued by the patient on post-operative day two without complication. The suprascapular nerve originates from C5 root or upper trunk of the brachial plexus. It provides up to 70% of the afferent fibers from the shoulder and the overlying skin (1). This nerve can be identified with ultrasound as a hypoechoic structure exiting laterally from the C5 nerve root / upper trunk as the transducer is moved caudally from the interscalene level. It is well known that interscalene brachial plexus blockade provides post-operative analgesia for shoulder surgery (2); however, the incidence of ipsilateral hemi-diaphragmatic paresis is nearly 100%(3). Hemi-diaphragmatic paresis is significantly less with supraclavicular block, about 50% (2). Typically, supraclavicular catheters are not recommended for shoulder surgery as these blocks are performed distal to the exit of the suprascapular nerve (2), important in shoulder innervation. A selective suprascapular catheter could provide the desired analgesia with even less risk of phrenic nerve blockade, as these blocks are performed more laterally. This patient undergoing shoulder surgery presented a challenge for post-operative analgesia due to his chronic opioid use and obesity / restrictive lung disease with previous inability to tolerate phrenic nerve paralysis from an interscalene nerve block. Placement of a suprascapular perineural catheter provided shoulder analgesia with no clinical evidence of hemi-diaphragmatic paresis. This case illustrates a technique to provide effective post-operative shoulder analgesia to a patient with pulmonary dysfunction and chronic opioid use. 1. J Shoulder Elbow Surg 2008;17:500-502. 2. Regional Anesthesia and Acute Pain Management 2007;403- 425. 3. Anesth Analg 1991;72:498 - 503. [Suprascapular Nerve] A223 DUM SPIRO, SPERO: USE OF CONTINUOUS THORACIC PARAVERTEBRAL BLOCKADE AND DEXMEDETOMIDINE INFUSION FOR ANALGESIA IN A CHILD WITH METASTATIC OSTEOSARCOMA AND POSTOPERATIVE DELIRIUM L. Le-Wendling, A. Munro Anesthesiology, University of Florida, Gainesville, FL, USA Introduction: One of the less studied but increasingly frequent challenges in pain medicine is the pediatric patient with chronic pain who then presents with severe postoperative pain. Even more difficult is the analgesic management of a pediatric patient with acute pain and postoperative delirium. Regional anesthesia, selective multimodal analgesics, and a multidisciplinary approach are required to achieve optimal care. Case presentation: A 13 y.o. male with a history of neuroblastoma and radiation-induced left pelvic osteosarcoma presented with a small bowel obstruction that required small bowel resection with primary anastomosis. The patient had been on chronic analgesics that included baclofen 10mg per os (PO) three times daily, methadone 40mg PO twice daily, oxycodone 15MG PO every 6 hours as needed and pregabalin 200mg PO three times daily. Despite multiple adjustments to his opioid patient-controlled analgesia, the patient reported no relief in his severe abdominal pain from his surgery as well as hallucinations. The Regional Anesthesia and Perioperative Pain Management Service was consulted. Because of thrombocytopenia, bilateral thoracic paravertebral catheters were placed instead of a continuous epidural catheter. Due to his worsening postoperative delirium, a dexmedetomidine infusion was utilized for further analgesia allowing the intravenous fentanyl infusion to be weaned to a lower basal rate. The use of seroquel and midazolam led to a resolution of the delirium. Discussion: This case highlights many important issues in acute on chronic pain management in the pediatric patient: the importance of using a multimodal technique for pain management, the utility of bilateral paravertebral catheters for postoperative somatic pain in a patient with coagulation abnormalities, and the difficulties in medication selection when managing pain in a pediatric patient with postoperative delirium. Furthermore, uncontrolled pain in childhood can lead to problems with emotional wellbeing and academic achievement, increase the risk for developing depression and anxiety, and predispose patients to developing chronic pain in adulthood. Unfortunately, there is a paucity of randomized controlled trials focusing on acute perioperative pain management in the pediatric patient with chronic pain, resulting in treatment options that are rarely evidence-based. References: 1. Alfonso et al. Rev Bras Anestesiol 2012; 62:118-133 2. Belgrade et al. Pain Medicine 2010; 11:1819-1826 3. Berta E et al. Paediatr Anaesth 2008;18:593-7 4. Bhalla et al.J Anesth. 2012; Sep 25 5. Bosenberg A. Pediatric Anesthesia 1155-5645 6. Brown RH, Tewes PA. Anesthesiology 1989;70:1011-2 7. Dahlgren N, Tornebrandt K. Acta Anaesthesiol Scand 1995; 39: 872-80 8. Faccenda KA, Finucane BT. Drug Saf 2001; 24: 413-22 9. Gerlach et al. The annals of pharmacotherapy 2007 Vol 41 10. Giaufre E, Dalens B, Gombert A, et al. Anesth Analg 1996; 83: 904-12 11. Gilbert J, Hultman J. Acta Anaesth Scand 1989;33:142-5 12. Howard, R. JAMA 2003; Vol 290; 18 13. Ivani, G et al. Pediatr Anesth 2007;520-33 14. Lonnqvist, PA. Anaesthesia. 1992;47:607-9 15. Mason et al. Anesthesia-Analgesia.org Nov 2011 113: 5 16. McMorrow et al. Pediatric Emergency Care Mar 2012 28:3 17. Phan et al. Pediatric Drugs 2008; 10 (1): 46-69 Funding: none A224 ISOLATED LUMBAR RADICULAR SYMPTOMS IN THE CONTEXT OF SEVERE MULTILEVEL LUMBAR SPINAL STENOSIS: A CASE OF CONTRASTING NATURAL HISTORY OF DISC EXTRUSION AND SPINAL STENOSIS K. Namiranian, M. Rahbar 1 2 Anesthesiology, Baylor College of Medicine, Anesthesiology, Veterans Affairs Medical Center, Houston, TX, USA A 65 years old Hispanic male was referred to our pain service for the treatment of his recent onset right flank pain. The onset of pain was sudden, without any inciting event, located over his right flank with radiation to his lower abdominal and inguinal areas. The patient has had a history of chronic low back pain with bilateral knee pain for several years. His chronic pain in the lower extremities is highly suggestive of neurogenic claudication; He uses a walker to lean forward when he walks and his pain alleviated very soon after sitting down. The examination of the knees was unremarkable. The work-up for urinary stone disease done by patient´s primary care provider was negative. An MRI of lumbar spine showed post- laminectomy changes at L4 and L5 levels, multilevel spinal canal stenosis most severe at L2-3 causing cauda equina compression, intervertebral disc extrusion with caudal migration at T12-L1 and disc extrusion with rostral migration at T11-12. The flank pain was very intense and unresponsive to oral pain medications. This pain however, spontaneously subsided, two months after its onset. By the time the patient was seen in the pain clinic, he had no complaint of right flank pain. We related the flank pain to his disc extrusion at T11-12 causing nerve root impingement and not at T12-L1 which was more central and not causing any nerve root impingement. As expected, a followup lumbar spine MRI showed that the T11-12 disc extrusion completely resolved spontaneously. However, the disc extrusion at T12-L1 and severe spinal stenosis causing cauda equina compression at L2-3 seem to have remained unchanged. The patient chose to have no treatment for his spinal stenosis and was quite satisfied with the outcome. Conclusion: The presentation of radicular pain can lead clinicians in the identification of the location of nerve root injury, even in structurally complicated post-surgical multilevel spinal pathology. Careful review of actual MR images is essential, in order to make clinical-radiographic correlation. In formulating a treatment plan, the natural history of the disease causing the main complaint must be considered. Large migrated disc extrusions are more likely to resolve spontaneously and surgical treatment is often not necessary. A225 SAFE USE OF HIGH-DOSE TANDEM PARAVERTEBRAL CATHETERS FOR MULTIPLE RIB FRACTURES IN AN ELDERLY PATIENT B.R. O'Donnell, S. Khezri, I. Bentov, S. Chiu, A. Stogicza, W.T. Edwards, M. Depinto Anesthesiology and Pain Medicine, Harborview Medical Center/Univ of Washington, Seattle, WA, USA Introduction: We report use of two paravertebral catheters placed in an elderly patient with multiple one-sided rib fractures (4-10) and their successful use for 4 days employing a high rate infusion without local anesthetic toxicity. Case report: A 96 year-old male had fallen off a ladder injuring his left side: fracture of ribs 4-10, small apical pneumothorax, pulmonary contusion, T12 anterior compression fracture, L1-L5 transverse process fractures, lumbar hernia, and retroperitoneal hematoma. He was not responding well to hydromorphone PCA + oral acetaminophen, and the Pain Relief Service was called to assess suitability of epidural catheter placement. It was expected that the hypotension, induced by blockade of the sympathetic nerve fibers to the heart or by covering the 7+ spinal segments affected, would likely prohibit a sufficient concentration of local anesthetic for optimum benefit. It was proposed that two paravertebral catheters be placed in lieu of the epidural catheter. After obtaining informed consent, the patient was placed in the right lateral decubitus position. Using a modified Greenglass technique (1), a 17 gauge Touhy needle was advanced ~1 cm beyond the T6 transverse process and 3 cm of catheter was advanced beyond the needle tip. With the position unchanged, using the same technique, a second catheter was placed at the T9 level. After a negative test dose of 3 mL of 1.5% lidocaine containing 15 mcg of epinephrine, a loading bolus of 5 mL of 0.5% ropivacaine was injected into each catheter. Infusions of 0.2% ropivacaine at 6 mL/hr were initiated in each paravertebral catheter. The next day revealed good pain relief (0-3/10) but difficulties with deep inspiration and coughing. Both infusions were increased to 8 mL/hr. Assessment another day later revealed improved pain relief (0-2/10) but continued difficulties with deep inspiration and coughing. The patient denied signs of local anesthetic toxicity (ringing in the ears, metallic taste in the mouth), so both infusions were increased to 10 mL/hour. Concern was exhibited as the total rate of infusion was substantially higher than maximally utilized (0.2% ropivacaine at 12 mL/hr, Lönnqvist PA, personal communication). Nonetheless, the patient was maintained on the high rate infusions for another two days with no symptoms of local anesthetic toxicity. ECG showed no dysrhythmia or signs of altered conduction. The catheters remained in place for four days with continued relief. At conclusion of the infusion, ropivacaine levels were 2.8 mcg/mL, above the maximum tolerated levels of 2.2 mcg/mL noted by Knudsen et al. (2), but comparable to bupivacaine levels reported by Dauphin et al. (3) After catheter removal, the patient's pain was sufficiently controlled with a combination of oxycodone and acetaminophen. Discussion: This case demonstrates that tandem paravertebral catheters can be placed to achieve regional anesthesia in circumstances unavailable for treatment via epidural catheter. The lack of hemodynamic difficulties or local anesthetic toxicity reveals the safety of this method used to manage multiple rib fractures. References: 1. Anes. Clin. N. Amer. 2000 Jun;18(2):347-353. 2. Br. J. Anaesth. 1997 78: 507-514. 3. Can. J. Anes. 1997 44(4): 367-370. A226 SUCCESSFUL PERIOPERATIVE ANALGESIA OF ANTERIOR ILIAC CREST BONE HARVEST USING A CONTINUOUS TRANSVERSALIS ABDOMINIS PLANE BLOCK T. Ozelsel, B. Tsui, J. Green Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Each year, more than 500,000 bone graft procedures are performed in the United 1 States, and approximately 2.2 million are performed worldwide, with significant cost. Post-operative pain is considered the most common complication of iliac crest bone harvest; other significant 2 complications include nerve injury, hemorrhage, fracture, hernia, and ureteral injury. Chronic pain is estimated to develop in between 20% and 39% of all patients. Acute pain can lead to difficult post3 operative patient management and prolonged hospitalization. Materials and methods: We describe the use of the new Pajunk MultiSet 211156-40E catheter-over4 needle unit in the postoperative management of postoperative pain in a patient receiving an anterior iliac crest bone graft harvest. Results: The catheter was run in intermittent bolus technique for 48 hours post-operatively with good clinical success. Discussion: Different methods of regional anesthesia have been described in the management of 5,6,7 post-operative pain in patients for bone graft harvest with varying degrees of success. In our experience pain continues past the duration of single-shot nerve blockade and needs to be controlled continuously. Further the varying surgical techniques employed in harvesting bone graft affecting 8 9 different nerves in the still not fully understood innervation of the iliac crest make a differentiated approach in analgesia necessary and will offer ground for further clinical investigation. References: 1. Giannoudis PV, Dinopoulos H, Tsiridis E: Bone substitutes: an update. Injury 2005; 36 Suppl 3: S20-S27 2. Boone DW: Complications of iliac crest graft and bone grafting alternatives in foot and ankle surgery. Foot Ankle Clin. 2003; 8: 1-14 3. Jäger M, Westhoff A, Wild R: Knochenspanentnahme am Becken. Techniken und Probleme. Orthopäde 2005; 34: 994 4. Ip V, Bouliane M, Tsui B: Potential contamination of the surgical site caused by leakage from an interscalene catheter with the patient in a seated position: a case report. Can.J.Anesth. 2012; 10.1007/s12630-012-9798-1 5. Hebbard PD: Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block. Can J Anaesth 2009; 56: 618-20 6. Chin KJ, Chan V, Hebbard P, Tan JS, Harris M, Factor D: Ultrasound-guided transversalis fascia plane block provides analgesia for anterior iliac crest bone graft harvesting. Can J Anesth (2012) 59:122-123 7. Chiono J, Bernard N, Bringuier S, Biboulet P, Choquet O, Morau D, Capdevila X: The UltrasoundGuided Transversus Abdominis Plane Block for Anterior Iliac Crest Bone Graft Postoperative Pain Relief. Reg Anesth Pain Med 2010;35: 520-524 8. Zouhary K: Bone Graft Harvesting From Distant Sites: Concepts and Techniques. Oral Maxillofacial Surg Clin N Am 22 (2010) 301-316 9. Gray´s Anatomy (40th English Edition) Editor; Susan Standring Chapter 79, Pg. 1356; "Pelvic Girdle, Gluteal Region and Thigh: Hip Bone; Ilium" Churchill Livingstone, Elsevier, 2008 Funding: no external funding Conflict of interest: The continuous nerve block set (Pajunk MultiSet 211156-40E) was a modified and re-designed continuous nerve set by Dr. Ban Tsui A227 THE USE OF ULTRASOUND GUIDANCE FOR SAPHENOUS NERVE ALCOHOL NEUROLYIS - A CASE STUDY V. Patel, P. Kim, M. Ko, S. Shaikh Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York City, NY, USA Introduction: The Saphenous nerve gives rise to branches that innervate not only cutaneous areas of the anterior and medial knee, but also the anterior inferior capsule of the knee joint itself(1). Recent publications show the feasibility of performing ultrasound guided saphenous nerve block that spares motor blockade for pain control in surgical procedures involving the knee(2). In this case study, we investigate the use ultrasound guidance to perform an alcohol neurolysis of the saphenous nerve in a woman with chronic right knee pain. Case: A 79 y/o Female with a history of CAD, hypertension, osteoarthritis and chronic back pain presented to Pain Management clinic for treatment of chronic dull achy right knee pain (VAS 6-8/10) that worsens with activity, interfering with her daily activities and ambulation. A trial of saphenous nerve block had provided her with decreased pain prior to the procedure. After obtaining informed consent, the patient was given light sedation with midazolam. The area in the midthigh was prepped and draped in the usual fashion. A high frequency ultrasound transducer was used to visualize the saphenous nerve in the adductor canal. [Ultrasound probe position] A 22G 2 inch needle was guided to an intraneural position. After negative aspiration of blood, a total of 20mL of solution (12mL of 40% alcohol and 8mL of 0.25% Bupivicaine) was injected. [Ultrasound Image of Saphenous Nerve] The patient was monitored for 4 hours post procedure and only complained of mild discomfort in the injection area. Results: Initial results (1 week and 1 month follow up) have been promising. Despite loss of sensation on the medial leg from knee extending to mid foot, the patient has had a greater than 60% reduction in her pain scores (VAS 2-3) with improved ambulation and quality of life. Furthermore, there has been no evidence of any motor function compromise. References: 1) Benzon H et al. Anesthesiology. 2005; 102:633-8 2) Saranteas T et al. RAPM. 2011 Jul-Aug;36(4):399-402 A228 POST-OPERATIVE EPIDURAL PAIN MANAGEMENT IN PATIENT WITH MULTIPLE SCLEROSIS AND BACLOFEN PUMP K. Patel, D. Elmofty University of Chicago, Chicago, IL, USA Multiple Sclerosis (MS) occurs in genetically susceptible patients following various triggering events leading to an autoimmune reaction resulting in demyelination and glial scaring of the brain and spinal cord. This, in turn, causes a conduction blockade on sodium channels of neural pathways resembling a neural blockade caused by local anesthetics. Patients often have various neurological deficits including: sensory, motor, cranial nerve, spasticity, etc. Regional and neuro-axial anesthetic techniques in patients with progressive neurological diseases are often not preferred because of the difficulty in assessing new or progressive neurological deficits perioperatively. We present a case with a patient with MS with previous intrathecal baclofen pump, in which a thoracic epidural was placed for perioperative pain management. The patient is a 46 year old ASA 3 female with past medical history significant for MS with baseline1/5 lower extremity weakness and loss of sensation. Patient is wheel chair bound. She had functional use of her bilateral upper extremities with occasional weakness and loss of sensation. She suffered from severe upper and lower extremity spasms and had an intrathecal baclofen pump implanted. She presented for cystectomy and ileal conduit secondary to her history of neurogenic bladder with vesiculvaginal fistula. Epidural analgesia was discussed with the patient preoperatively secondary to concerns of postoperative respiratory dysfunction from narcotics and patients underlying intercostals muscle weakness. There was extensive discussion with the patient regarding risk/benefits for epidural analgesia with emphasis on the possibility for worsening neurological deficits and difficulty in assessing these deficits perioperatively Because of her pre-existing severe neurological deficits, the patient consented for a thoracic epidural in an attempt to avoid worsening of her respiratory functional status postoperative. Preoperative thoraco-lumbar spine radiography showed the baclofen pump catheter entered at L2-L3 interspace, and terminated at T11-T12 with severe scoliosis. An epidural was placed at T8-T9 without fluoroscopic guidance avoiding entry level at L2-L3. The patient was started on a bupivicaine 0.1% and hydromorphone 20mcq/mL solution infusing at 3mL/hr with a 2mL every 20 min PCEA. Patient had a bilateral T6-L1 sensory level. Patient tolerated the epidural well, with excellent pain control and no new neurological deficits or complications. The epidural was removed on post-operative day 4. Patients with multiple sclerosis present with unique challenges when it comes to perioperative pain management. It is important to develop an analgesic plan that will preserve respiratory function. Epidural analgesia offers many benefits but in a patient with baseline neurological deficits, placement can be controversial. In our patient, the benefits outweighed the risk of difficulty in evaluating for new or progressive neurological deficits. Placement of the epidural was also challenging secondary to patient's severe scoliosis and intrathecal catheter. This patient required a preoperative radiography to evaluate the position of the intrathecal catheter. Patient education and extensive risk/benefit discussion is extremely important in these situations. Furthermore, detailed documentation of a preoperative and a daily neurological exam needs to be conducted. A229 LOWER LOBE LUNG INFILTRATE: INFECTION, ASPIRATION OR JUST VOLUME LOSS K. Patel, T. Malik University of Chicago, Chicago, IL, USA Continuous interscalene block is an effective and safe technique for inpatient and outpatient pain control. Large scale observational studies of ambulatory catheter programs reveal most patients were successfully managed with daily phone calls required limited interventions on the part of managing 1 anesthesiologists. However; it is not a completely benign intervention. Infection, hematoma, dislodgement and entrapment are the most common complications. Phrenic nerve palsy is a common 2 complication after an interscalene block. We report a case where an interscalene ambulatory catheter placed for postoperative pain control for shoulder surgery caused ipsilateral diaphragmatic dysfunction and radiological findings on CXR resulting in unnecessary diagnostic and therapeutic interventions. Case report: A 52 year old, ASA 2 patient, was scheduled for right arthroscopic rotator cuff repair surgery. An interscalene catheter was placed using ultrasound an hour before surgery. The Catheter was activated with 30 ml 0.5% bupivacaine. The patient developed loss of sensation and motor block in C5, C6, C7 distribution within 30 min. Patient remained stable and complained of no shortness of breath. The surgery was done in sitting position. She received a propofol infusion (100 mcg/kg/minutes) for sedation. No airway support was needed, and the patient breathed spontaneously throughout the case with 4L nasal cannula. Post-operatively, the patient was very comfortable and was sent home with a disposable local anesthetic pump. She received 0.125% bupivacine at 6 mL/hr with 5mL bolus/hr as needed. At 9 pm that evening, she felt midthoracic posterior chest wall discomfort at interscapular level. She gave herself 5 ml bolus dose. Within 10 minutes she started feeling “choking” sensation. She spoke with the on call pain team resident who advised her to stop the infusion and go to the nearest emergency department. In the ED, her symptoms self-resolved, however based on her symptoms she received a cardiac and pulmonary embolism workup. Her cardiac enzymes and V/Q scan were negative. CT scan revealed bilateral lower lobe atelectasis, worse on right side. She was diagnosed with pneumonia despite normal CBC and CRP. She was empirically started on IV antibiotics. IV heparin started in ER was discontinued. The Interscalene catheter was removed and intravenous hydromorphone started for surgical pain control. She was admitted with the working diagnosis of right lower lobe pneumonia, possibly aspiration. Her symptoms quickly resolved. The managing physician was informed by the pain service that her right lower lobe volume loss most likely due to phrenic nerve palsy from interscalene catheter and recommended the patient be discharged since preliminary work-up was negative. Discussion: Continuous interscalene block has been shown to be an effective modality for postoperative pain control. However, as with any procedure, risks are always present. We suspect that unilateral phrenic nerve palsy caused unilateral diaphragmatic paresis, which resulted in a right lower lobe atelectasis and the patient's symptoms. This case report illustrates that importance of good communication and education between the services involved as well as with the patient. Effective communication and regular follow-up in the peri-operative period will prevent such complications from occurring. A230 PARASPINOUS AND CHEST WALL ABSCESSES FOLLOWING THE PLACEMENT OF A CONTINUOUS THORACIC PARAVERTEBRAL BLOCK AND A CHEST TUBE C. Lin, B.A. Pearce-Smith, J.E. Chelly Division of Acute Interventional Perioperative Pain, UPMC - Presbyterian Shadyside Hospital, Pittsburgh, PA, USA Introduction: Continuous paravertebral block is an effective method for managing acute chest pain for trauma patients who have suffered rib fractures. We report a case of a patient, without a previous history of immunosuppression, who developed paraspinous and chest wall abscesses. This case report highlights the differential etiology of abscesses following invasive procedures in trauma patients. Case report: A 48 year old previously healthy male suffered a 10 foot fall from ceiling scaffolding and nd th presented to the emergency department with a right clavicle fracture, right 2 - 6 rib fractures, right small pneumothorax and a possible diaphragmatic injury. There was no antecedent history of MRSA. th The patient urgently received a right chest tube in the emergency department along the 4 interspace. On post-trauma day (PTD) #1, operative video-assisted thoracic surgery demonstrated a small hemothorax, with no diaphragmatic injury. On PTD #2, the patient received a single continuous thoracic paravertebral nerve block for acute pain management. The nerve block was placed at the right T6 level under strict aseptic technique, including sterile Chloraprep© skin preparation, facemask, gloves, the use of a prepackaged B Braun custom catheter kit and a large drape. The paravertebral nerve block catheter remained in situ for a total of 3 days,during which time he received no antibiotic therapy. On the following day, the paravertebral nerve block catheter was removed (PTD #6), the patient developed a leukocytosis 13.5, fever 39.2 °C and noted tenderness and purulent drainage from the single right PVB insertion site. Intravenous Unasyn was begun and bedside surgical debridement was performed - Cultures of the PVB abscess site grew MRSA. CT Chest and CT Thoracic Spine demonstrated a 4x1cm superficial fluid collection in the Right Paraspinous Muscle, without extension into Paravertebral Space and without Thoracic Spine invasion. Concurrently, his chest tube site also developed a purulent abscess, also requiring I&D, again yielding positive cultures for MRSA. Subsequently, the patient underwent a full operative surgical irrigation and debridement of the PVB site. He was switched to intravenous vancomycin for coverage of MRSA. The patient recovered, and was discharged PTD #12 on oral Bactrim without further complications Figure 1 [Right PVB Abscess] Discussion: Trauma patients with rib fractures are appropriate candidates for continuous thoracic . 1,2 paravertebral nerve blocks to manage chest wall pain and improve respiratory function Although, the cited risks of thoracic paravertebral nerve blocks include pneumothorax, pleural puncture, bleeding, epidural or intrathecal spread, infection, hypotension and spinal headache, these complications are rare. However, the fact that this patient developed concurrent chest wall and superficial paraspinous abscesses, with the same organsim, suggests that the etiology of such infectious complications may be more complex. Bibliography: 1/Adelman MH, I. C. (1946). Acute aseptic meningitis following paravertebral lumbar sympathetic blocks. Anesthesiology, 7:422-5. 2/Chelly, J. (2012). Paravertebral blocks. Anesthesiol Clin., 30(1):75-90. 3/Karmakar MK, C. L. (2003). Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest, 123(2):424-31. A231 TREATMENT OF FIFTH DIGIT ISCHEMIA WITH BRACHIAL PLEXUS BLOCKADE, VIA A SUPRACLAVICULAR APPROACH, AFTER FAILED STELLATE GANGLION BLOCK J. Pierson, M. Anitescu Anesthesiology and Critical Care, The University of Chicago, Chicago, IL, USA A 33-year-old gentleman with a history of left ulnar artery thrombosis secondary to hyperhomocysteinemia was referred to the University of Chicago Pain Management center for a stellate ganglion block. Pt was initially managed ulnar artery thrombectomy, however, suffered continued fifth digit ischemia from emboli. Pt had been unsuccessfully medically managed with heparin, lovenox, Coumadin, aspirin and nifedipine. Under fluoroscopic guidance, a spinal needle was advanced with sterile technique to the junction of the C7 vertebral body and the transverse process, with appropriate spread of Omnipaque 180 after negative aspiration. Once appropriate placement was confirmed, 5 mL 0.25% bupivacaine and 5 mL 1% lidocaine with 40 mg Kenalog was injected. The patient experienced no relief in his pain, and no circulatory or temperature changes were noted. After failed stellate ganglion block, the brachial plexus was identified under ultrasound in the supraclavicular region. Under sterile technique, a 22-gauge 2-inch nerve stimulator needle was advanced, and appropriate twitches were obtained at less than 0.4 mA. No heme was aspirated, no paresthesias were eliecited. Then, a total of 30 mL solution consisting of 40 mg Kenalog and 0.25% bupivacaine was injected in 5 mL increments. Appropriate hydrodissection was noted under ultrasound. The patient tolerated the procedure well. Upon completion of the procedure, patient noted resolution of his left 5th digit pain. Upon follow up visit with his orthopedic surgeon, the patient reported complete resolution of his symptoms. His physical exam was consistent with intact peripheral circulation of his 5th digit by color, temperature, pulsation and lack of pain. The patient was placed on long term anti-coagulation medications for management of his hyperhomocysteinemia. Stellate ganglion blockade is a well described intervention for improvement of upper extremity circulation. In our case, we describe an alternative approach for upper extremity symathectomy aimed at improving peripheral circulation. Because the brachial plexus contains the sympathetic fibers of the upper extremity, brachial plexus blockade should result in upper extremity sympathectomy and thus improve distal collateral circulation in the setting of thrombosis, emboli or spasm. The supraclavicular approach was chosen because the entire sensory, motor and sympathetic innervations of the upper extremity is carried in just three nerve structures confined to a small surface area, creating a highly predictable and dense block. In the setting of failed stellate ganglion block, the supraclavicular approach to the brachial plexus can provide satisfactory upper extremity sympathectomy and improved circulation in the setting of distal artery thrombosis, emobli or spasm. A232 TARGETED TWO-LEVEL THORACIC EPIDURAL BLOOD PATCHES FOR SPONTANEOUS INTRACRANIAL HYPOTENSION DUE TO LEAKING MENINGEAL CYSTS J.J. Rivera-Melendez, F. Elahi, T.L. Dann, R. Sripada Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Introduction: Spontaneous intracranial hypotension is a rare disease that occurs in 5 out of 100,000 people.(1) Besides conservative management with bed rest, caffeine, hydration and, abdominal binder, the mainstay of treatment for SIH is the epidural blood patch. (2, 3) A multilevel CSF leak may be suspected after performing an EBP 1-2 times with no symptom improvement.(1) We present a case of SIH caused by leaking meningeal cysts effectively treated by a targeted two-level EBP. Case report: A 64 yo male with a history of bifrontal headaches self-treated with acetaminophen over the last two years presented to our institution. He describes his headaches were getting progressively worse, related to position, and difficult to manage after he underwent rotator cuff surgery one month prior. He sought medical attention at an outside hospital, including a lumbar puncture and then an epidural blood patch without success. The patient was started on conservative management and the acute pain service was immediately consulted. At the time, it was suggested that a repeat epidural blood patch would not be beneficial given the failure of the first one. A spine MRI showed intracranial hypotension and suggested a possible CSF leak at the AO joint and demonstrated meningeal cysts in the thoracic spine. Subsequently, it was advised to pursue a study to determine the presence and location of a CSF leak. A CT myelogram demonstrated contrast extravasation through cysts at C7-T1 and T6. He was consented for fluoroscopically-guided epidural blood patches. An 18-Ga Touhy was advanced into the C7-T1 interspace and the epidural space and confirmed with fluoroscopy, then repeated at the T6-T7 level. A total of 12 ml of the patient´s blood was injected at C7-T1 and 15 mL at T6-T7. The patient did not experience any complications and noted slight improvement immediately. He was discharged headache-free three days later. Discussion: This case reveals an unusual occurence in which a headache evolved over time to become a positional headache. The first attempt at a blood patch in an outside hospital failed as it did not target the unknown leaking levels by assuming it was caused by a previous LP. Myelography with iodinated contrast followed by thin cut CT of the entire spine has been shown to define accurately the location and extent of a CSF leak.(4) CSF-leaking meningeal cysts were discovered at the thoracic level allowing effective treatment with a targeted two-level fluoroscopically-guided epidural blood patch. References: 1) Kim SY, Hong JH. Epidural Blood Patches in a Patient With Multi-level Cerebrospinal Fluid Leakage That Was Induced by Spontaneous Intracranial Hypotension. Korean J Pain 2010; 23:46-50. 2) Schievink WI. Spontaneous spinal cerebrospinal fluid leaks. Cephalalgia 2008; 28:1345-56. 3) Sencakova D, Mokri B, McClelland RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology 2001; 57:1921-3. 4) Schievink WI, Meyer FB, Atkinson JLD, Mokri B. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 1996; 84:598-605. Funding: None A233 A CONTINUOUS PERIPHERAL NERVE BLOCK FOLLOWING A TRAUMATIC BELOW KNEE AMPUTATION IN A 10 YEAR OLD CHILD R. Sachdeva, S. Millerchip, M. Ziauddin, C. Hillermann UHCW, Coventry, Coventry, UK Introduction: Continuous peripheral nerve catheters have been used in paediatrics for orthopaedic 1 procedures for short duration . There are very limited studies of the use of continuous infusion of low 2 dose local anaesthetic agents for long term pain management in patients following limb amputation . Kotiniemi et. al. emphasized the fact that inadequate pain relief in children was one of the predicting factors of problematic behavioural changes in the near postoperative period. These changes could 3 persist for three to four weeks after surgery . We present a case of a traumatic below knee amputation (BKA) after dog bite managed with continuous sciatic nerve block for 10 days. Case study: A 10 year old girl (42kg) was admitted to the hospital following a dog bite. Reconstructive surgery failed and the patient underwent a BKA The patient was anaesthetised using rapid sequence induction with thiopentone and suxamethonium and maintained with sevoflurane 3.0% in O2/Air, atracurim, morphine (6mg) and paracetamol. At the end of the procedure a continuous sciatic nerve catheter was placed with ultrasound in the popliteal fossa at the bifurcation of the sciatic nerve and a 15 ml bolus of 0.25% L-Bupivacaine was given through the catheter followed by infusion of 0.125% L-Bupivacaine at fixed rate of 5ml/hr. A single shot mid-thigh saphenous nerve block (ultrasound guided) was also performed with 7ml of 0.25% L-Bupivacaine. Postoperatively the patient was comfortable and required no breakthrough analgesia in PACU and was transferred to the paediatric high dependency unit. Regular post-operative analgesia prescribed was paracetamol, codeine phosphate, ibuprofen and gabapentin. Unfortunately in the following morning catheter was dislodged. After 3 hours the patient started getting severe phantom limb pain which was difficult to control with additional opioid therapy. She was brought back to theatre for reinsertion of the catheter under general anaesthesia. L-bupivacaine (15ml of 0.25%) with clonidine 80 micrograms was injected around the nerve and the continuous infusion of 0.125%L-bupivacaine was restarted. The patient was reviewed daily by the acute pain team and the catheter was removed on day 10. She was discharged the following day with regular paracetamol, ibuprofen and gabapentin and did not require any supplementary opioids. She could mobilize in a wheel chair and didn´t complain of any phantom limb pain. She is undergoing rehabilitation and physiotherapy in the community. Conclusion: Use of continuous peripheral nerve catheters in our patient provided excellent pain relief and avoided the development of phantom limb pain without the risks associated with opioids. References: 1. Dadure C, Pirat P, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003; 97: 687-90. 2. Ivani G, Codipietro L, Gagliardi F, Rosso F, Mossetti V, Vitale P. Along-term continuous infusion via a sciatic catheter in a 3-year-old boy. Paediatr Anaesth 2003; 13: 718-21. 3. Kotiniemi LHRyhänen PTMoilanen IK Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia.1997;52:970-976. A234 IDENTIFICATION OF THE LOCATION OF PERIPHERAL NERVE CATHETERS DURING PERIPHERAL NERVE BLOCKS USING PUMPING TECHNIQUE L. Arora, V. Salmasi, H. Elsharkawy Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA Introduction: Optimum positioning of Peripheral Nerve catheter is vital for successful nerve block. There is incidence of secondary catheter failure in spite of good nerve localization on ultrasound, due to improper positioning around the nerve. One of the main reasons is difficulty to localize the tip of Peripheral nerve catheters in the desired field. We described a novel technique called Pumping maneuver that can really be helpful to achieve this goal. Discussion: One of the main reasons of malposition is difficult to identify the tip of these small peripheral nerve catheters around the nerve. So we used our novel technique called Pumping maneuver in a series of four patients who got ultrasound guided femoral, anterior sciatic, Popliteal and interscalene peripheral nerve catheters for postoperative pain relief to identify the location of the tip of the peripheral nerve catheter using color Doppler. After introduction of the catheter 5 cm beyond the needle tip in the desired field of block, the guide wire was re-introduced in the catheter and was moved back and forth. This movement produced color Doppler effect in the area around the nerve on using ultrasound color Doppler that helped us to identify the tip of peripheral nerve catheter. Postoperatively pain was well controlled in all these patients using continuous infusions with minimum requirement for opioids reflecting successful blocks. Pumping Maneuver Pumping the stylet in and out of a stationary needle shaft increases the echogenicity of the needle shaft and tip, thereby facilitating needle localization. We applied it to the catheters. The increased echogenicity has been attributed to the formation of micro bubbles inside and outside the catheter. It can be achieved using the color Doppler [Supraclavicular nerve block] [Sciatic nerve identification] Conclusion: Confirmation of catheter around the nerve can be difficult to visualize even with USG. Pumping maneuver along with color Doppler can help the user to identify the catheter and achieve successful block. This technique has not been studied before. It is based on our clinical experience, which requires future studies to establish its validity and reproducibility. A235 FEMORAL VEIN THROMBOSIS DISCOVERED DURING US GUIDED REGIONAL ANESTHESIA PROCEDURE B.U. Schmitz, K. Yates Anesthesiology, Texas Tech University HSC, Lubbock, TX, USA Case report: A 45-year-old female was scheduled for a post-operative ultrasound-guided fascia iliaca compartment block in the PACU after re-implantation of a total hip arthroplasty. The patient had an extensive medical history including a previous THA and consecutive hardware removal due to an infection, liver cirrhosis, peptic ulcer disease, upper GI bleeding, chronic pancreatitis, HTN and chronic lower back pain. During the ultrasound evaluation a hyperechoic structure, pulsating with the arterial pulse of the adjacent femoral artery was discovered in the femoral vein in the groin. In the longitudinal view this structures extended over more than two inch. The preliminary diagnosis of a deep vein thrombosis in the femoral artery was made and the primary orthopedic team and vascular surgery informed. A formal vascular ultrasound performed by radiology confirmed the diagnosis of a deep vein thrombosis on the left site. Though the thrombus was considered older the possibility of dislocation of the thrombus or thrombus parts was considered significant due to its high mobility. The patient underwent an insertion of an IVC filter the same day. During her postoperative course the patient did not experience any problems from her DVT. Discussion: Deep vein thrombosis is a common complication of total hip replacement surgery. Before the routine use of thrombosis prophylaxis the incidence of deep vain thrombosis was 40-60% and the incidence for proximal DVT 10-30% 7-14 days after major orthopedic surgery. Since the introduction of thrombosis prophylaxis the incidence of symptomatic DVTs decreased to 1.3-10% 1 within 3 month after surgery. Our patient had a significant elevated risk for DVT: repeated joint surgery, infection and prolonged period of no or minimal physical activity. A fascia iliaca compartment block provides good pain control after hip surgery and is a valuable alternative to the lumbar plexus block. It is a relatively superficial block that can be easily and successfully performed with ultrasound guidance, the patient remains supine and the block has a low risk for side effects and complications. The ultrasound evaluation includes the identification of the femoral vessels, the femoral nerve, the fascia lata and iliaca and the iliacus muscle, the needle is inserted more laterally to the transducer (compared to the FN insertion point) and a higher LA volume of 30-40 ml is injected within or right below the fascia iliaca. Only 3 incidences of diagnosis of a deep vein thrombosis during US guided regional anesthesia have 2,3 been reported in Pub Med , none of the patients had previous major orthopedic surgery, however anesthesiologists performing regional anesthesia should be aware of the potential for a proximal DVT especially in a patient undergoing repeat major orthopedic surgery. References: 1 Geerts WH. Prevention of Venous Thromboembolism Amrican College of Chest Physicians Evidence-Based Clinicak Practice Guidelines. CHEST 2008; 133:381-453S 2 Sites B, Spence B, Gallagher J, Beach M. On the Edge of the Ultrasound Screen: Regional Anesthesiologists Diagnosing Nonneural Pathology. Reg Anesth Pain Med 2006; 31:555-6 3 Sutin KM. Deep venous thrombosis revealed during ultrasound-guided femoral nerve block. Br J Anaesth 2005;94:247-8 A236 LATERAL PECTORAL NERVE BLOCKS AFTER BREAST AUGMENTATION M. Semenza II, G. Woodworth, J.-L. Horn Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA Introduction: Breast augmentation surgery is a commonly performed cosmetic procedure and can be associated with significant postoperative pain when the prosthesis is placed beneath the pectoralis major muscle. (1-3) Although thoracic intercostal nerves provide sensory innervation to the breast, the contribution of the pectoral nerves to post-breast augmentation pain has yet to be determined. We present the management of severe postoperative pain after breast augmentation surgery with lateral pectoral nerve blocks as well as the technique to block the nerves. Methods: A 36 year old female, ASA1 underwent bilateral breast augmentation surgery under balanced general anesthesia and experienced uncontrolled pain in the PACU with systemic medications. In order to improve analgesia and avoid hospital admission, lateral pectoral nerve blocks with back up paravertebral blocks were discussed with the patient. This patient had been consented in the preoperative area for a possible postoperative block. An HD 11 XE ultrasound machine with a L12-3 MHz probe (Philips, Bothell, WA) was used to perform the blocks. The probe was placed 2cm caudad and parallel to the mid clavicle. The pectoral arterial branch of the thoracoacromial trunk was identified in the fascial plane between the pectoralis major and minor muscles. After sterile prep and using sterile technique, a 10 cm 22 gauge Sonoplex Stim needle (Pajunk, Geisingen, Germany) was advanced under ultrasound in-plane next to the artery. Five ml of 0.5% ropivacaine was injected next to the artery after negative aspiration on each side. Results: Preblock pain score (VAS) was 3/10 at rest and 7/10 with deep breathing. Patient was unable to move due to uncontrolled pain despite maximum opioid administration. Within 5 minutes of the right side injection, the patient experienced complete pain relief at rest on that side with a VAS at 0/10. The contralateral side was then injected with the same results. During active mobilization and deep breathing her pain score was at 3/10 with pain control rated as being excellent. The patient did not require further analgesics and was discharged from the facility with good pain control 36 minutes post block. On telephone follow-up her pain control was rated as excellent without any side effects. The patient performed household tasks as usual until the block wore off about 8hrs later. She then needed opioids for the next 12hrs but was very satisfied with her overall pain control Conclusion: We report a case of successful blockade of the lateral pectoral nerves to improve postoperative analgesia following breast augmentation. This case confirms that significant pain afferents are carried by the lateral pectoral nerves after breast augmentation. Since those nerves travel in a discrete fascial plane that can be readily visualized on ultrasound and infiltrated with local anesthetics, it could become a valuable option for breast augmentation surgery. References: 1. Wallace MS et al. Pain 1996;66:195-205. 2. Vadivelu et al. The Am Surgeon 2008;74:285-296. 3. Blanco R. 2011. Anaesthesia 2011;66:847-848. [Lateral Pectoral Nerve Block] A237 INTERMITTENT HOARSE VOICE CONCURRENT WITH CONTINUOUS INTERSCALENE BRACHIAL PLEXUS INFUSION DUE TO DEFICIENT CAROTID SHEATH T.J. Shakespeare, B.C.H. Tsui, Edmonton Academy of Regional Anesthesia Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada Introduction: Hoarse voice after interscalene brachial plexus block for shoulder surgery is a common 1;2 side effect with an incidence of 0.8-31%. The anatomical basis for this is presumed blockade of the recurrent branch of the vagus nerve, although the mechanism remains unclear. Here, we describe a case of hoarseness following interscalene blockade, in which ultrasound was used to reveal the underlying cause and mechanism of hoarse voice. Material and methods: A 68-year-old woman, from whom consent was provided to describe the case, received an interscalene catheter with general anesthesia for total shoulder replacement. The patient had a BMI of 43.2, and physical examination revealed that the patient had a relatively short 3 neck. A catheter-over-needle assembly was inserted in-plane under ultrasound guidance between the upper and middle trunks of the brachial plexus. Fifteen mL of surgical mixture (0.5% ropivacaine and 0.125% bupivacaine) was injected into and remained in the interscalene space. After confirming catheter tip position on ultrasound, a further 5 mL of the surgical mixture was injected under ultrasound guidance. After this, the patient immediately experienced a hoarse voice and inability to cough, although she did not report respiratory compromise. Surgery proceeded uneventfully, and the patient experienced persistent hoarseness until the interscalene infusion was discontinued on postoperative day two. Results: On ultrasound, we observed local anesthetic extending from the interscalene space behind the anterior scalene muscle (ASM) and passing between the common carotid artery (CCA) and the internal jugular vein (IJV), surrounding the ipsilateral vagus nerve (Figure). [Figure] Ultrasound revealed that the carotid sheath (CS) was absent laterally but appeared intact medially, allowing passage of local anesthetic between the CCA and IJV. Absence of direct CS puncture was confirmed with real-time video recording, as was a small ASM, which may have created a reduced barrier between the interscalene groove and carotid vasculature, including the vagus nerve. Discussion: Our observations illustrate direct vagus nerve block due to local anesthetic spread secondary to interscalene block. In this case, ultrasound scanning helped to explain one of the common side effects of interscalene brachial plexus block and provided valuable, real-time information on the underlying mechanism. We encourage all regional anesthesiologists with access to ultrasound to use it for anatomical examination in cases where side effects and complications are present. Reference list: 1. Borgeat A, et al. Anesthesiology 2003; 99: 436-42 2. Liu SS, et al. Anesth. Analg. 2010; 111: 617-23 3. Ip V et al. Can. J. Anesth. 2012; 59: 1125-9 Funding disclosure: Dr. Tsui is supported by the Alberta Heritage Foundation for Medical Research and the Canadian Anesthesiologists' Society. Personal conflicts of interest disclosure: The Pajunk MultiSet 211156-40E is modified and redesigned by Ban Tsui. Dr. Tsui also has a patent licensing agreement with Pajunk. Figure: Local anesthetic spread from the interscalene groove (ISG; arrowheads) to the vagus nerve (V). Location of local anesthetic is indicated by asterisks. MS, middle scalene muscle; AS, anterior scalene muscle; IJ, internal jugular; C, carotid artery. A238 IMPORTANCE OF VIGILANT MONITORING AFTER CONTINUOUS NERVE BLOCK - LESSONS FROM A CASE T. Shuster Pain Management -Acute Pain, Cleveland Clinic, Cleveland, OH, USA Regional anesthesia is a common mode of postoperative pain management in the orthopedic setting. Preoperative nerve block had been proven to provide excellent analgesia through interrupting the sensation from a certain area or the surgical limb. Uncontrolled or escalating pain, despite the presence of a successful block, can be an indication for surgical complications and should not be overlooked. Tissue ischemia due to vascular injuries or compartmental syndrome should be suspected early should pain is not controlled in presence of regional anesthesia block. We describes a case of iatrogenic injury to the axillary artery during shoulder surgery in a patient who had continuous supraclavicular block, and, how vigilant monitoring helped in the diagnosis and timely management of ischemia in the upper extremity. The patient in this case report had a difficult dissection during the shoulder repair and an accidental injury to the axillary artery, which was not identified intraoperatively. The surgery lasted for 260 minutes and was associated with 300ml blood loss. Intraoperatively, the patient had stable hemodynamics and the surgeon reported a difficult, yet uncomplicated procedure. Post operatively, the supraclavicular catheter was connected to an infusion pump containing 0.2% Ropivacaine. The infusion was set up as PCA (patient controlled analgesia) to a basal rate of 8ml per hour and patient demand dose of 12ml every 60 min as needed. The patient's pain was originally well-controlled for the first few post-operative hours. Overnight, the pain starts to escalate in non-surgical sites; forearm and hand, which were partly masked by the regional nerve block. On physical examination the arm was slightly dusky, capillary refill was brisk, radial and brachial pulses were palpable and the hand was warm. The patient was given a top up dose through the supraclavicular catheter with 15cc of 0.5% Ropivacaine and she reported satisfactory relief of pain. Neurovascular checks were done hourly by nursing staff at this point to rule out any progressive ischemic injury. The next morning, examination at 0900 hrs showed that the hand was cyanosed, pulses were weak and patient had increasing pain in the hand and forearm. Nursing notified primary service, acute pain service, Vascular surgery service was consulted immediately, emergency angiography of the right upper limb was done and it showed a 3cm segment of occlusion of the axillary artery adjacent to the shoulder joint, with reconstitution at the level of the most distal part of the circumflex humeral artery. Immediate exploration of the patient's right axillary artery confirmed a partial occlusion. This was repaired by a subclavian artery to brachial artery bypass using sapheous venous graft. Pulses in the right upper limb returned. Post operatively, the patient recovered well and gained full function of the right upper limb. The patient was discharged home on the fourth postoperative day with full neurological and functional recovery. Currently, there are no recommendations regarding monitoring after nerve blocks. This case report aims to improve awareness about the need for vigilant monitoring, especially of the distal pulses after peripheral nerve blocks. Personal conflicts of interest disclosure: Nothing to disclose. A239 BILATERAL CONTINOUS PARAVERTEBRAL BLOCK WITH LOW DOSE KETAMINE FOR POSTOP PAIN MANAGEMENT FOLLOWING WHIPPLE´S PROCEDURE IN AN OPIOID TOLERANT PATIENT WITH SPINAL CORD STIMULATOR Y. Siddapura Ranganath, T. Brennan, R. Sripada, J. Rivera-Melendez Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA Case report: A 60 year old male with cancer of the head of pancreas presented for Whipple's procedure. The patient had a spinal cord stimulator placed one year before for Intractable back pain (with multiple back surgeries) and bilateral lower extremity pain. The laminotomy was performed at T10-11 with spinal cord stimulator electrodes at T8 and T9 as shown in the figure. The patient also had a history of chronic opioid use and was opioid tolerant. Other medical history included hypertension and asthma. [Fluorosopic image of spinal cord stimulator] A thoracic epidural was deferred preoperatively due to the presence of spinal cord stimulator at the desired site of puncture and the patient consented for a post-op regional technique if necessary. The intraoperative period was significant for high opioid utilization and the patient was started on a Ketamine infusion intra-operatively after a bolus dose. The patient was placed on a Dilaudid PCA (0.3 mg every 10 minutes) and ketamine infusion at 10 mg/hr postoperatively. On Postoperative day 1, he had a pain score of 4-5 at rest and 9-10 with activity. He was not interested in regional analgesia until he tried to ambulate which he was not able to tolerate. He consented for bilateral paravertebral catheters which were placed under ultrasound guidance by parasagittal technique at T7 - T8 level. Twenty ml of 0.25% Bupivacaine was injected through each catheter and an infusion of 0.2% Ropivacaine with Epinephrine was started at 9ml/hr through each catheter. The patient had significant pain relief with Pain score of 2 -3 at rest and 5-6 with activity. He was able to ambulate with assistance which he was not able to do before the procedure. The catheters were th removed on the 6 postoperative day. Discussion: Patients undergoing major abdominal surgery often receive a continuous epidural infusion for postoperative analgesia. However, when epidural analgesia is unwanted or contraindicated, the administration of parenteral opioids is the usual means used to relieve pain. In an opioid tolerant patient, pain control following major abdominal surgery without a regional anesthetic technique can be challenging. Bilateral paravertebral blocks can provide high quality analgesia and have been used successfully in the thoracic and abdominal regions as an alternative to central neuraxial blockade (1). Adjuvants may be particularly useful in opioid tolerant patients; the most thoroughly studied adjuvant is ketamine. In a Cochrane review, 27 of 37 trials found that perioperative subanaesthetic dose of ketamine reduced rescue analgesic requirements or pain intensity, or both (2). Postoperative pain relief should be carefully tailored in these cases by means of a management plan that notes previous spinal instrumentation and opioid tolerance. References: 1. Richardson J etal.Br J Anaesth. 2011 Feb; 106(2):164-71 2. Bell RF etal. Cochrane Database Syst Rev. 2006 Jan ;(1):CD004603 A240 EPIDURAL ANESTHESIA FOR CESAREAN SECTION IN A PARTURIENT WITH INTRACRANIAL TUMOR H. Skiff, S. Cohen, S. Shah, J. Grayson, A. Mohiuddin, S. Bhasin, R. Chhokra Anesthesiology, Robert Wood Johnson University Hospital-UMDNJ, New Brunswick, NJ, USA This 33-year-old white parturient ( Height 165 cm, weight 70 kg) was scheduled for elective CS to be followed two days later by a scheduled elective craniotomy for removal of left frontal lobe tumor. She was afebrile, BP 110/70. HR 80, had muscle weakness of the right face, arm and leg without trouble swallowing. She had slight slurred speech, and denied headache or photophobia. Her neurosurgeon reported a normal intracranial pressure without midline shift and preferred an epidural anesthesia for her CS, which would be, followed two days later by craniotomy. The risks and the benefits of epidural and general anesthesia were explained to the patient and her husband and they preferred epidural anesthesia. The epidural space was located at L3-4 interspace using 17g Hustead needle in right lateral decubitus position. The stylet was reinserted upon reaching ligamentum flavum each time the needle was [1] advanced 1-2 mm into the epidural space to reduce the risk of unintentional dural puncture . Following LOR to air injection, 3,5,5 and 5 ml 2 % lidocaine with 5mcg/ml epinephrine and 5 mcg/ml [2] fentanyl was administered by gravity technique via 22 inches extension tube into the needle. A 19g Arrow open-end tip catheter placed 4 cm in the epidural space. She had bilateral excellent L3-S5 epidural block for an uneventful cesarean section of a healthy but premature female (31 wks) with 1 5 Apgar scores of 8 and 8 . She received 2400 ml of LR solution, had an estimated blood loss of 800 ml and urine output of 800 ml and had stable vital signs throughout the operation. Following an uneventful course in the PACU, she was transferred to the surgical intensive care unit with epiduralPCA ropivacaine 0.025% with fentanyl 3 mcg/ml and epinephrine1 mcg/ml, 15 ml/hr, 4 ml PCA dose with lockout time of 10 min. The following day she had an episode of seizures, was intubated, connected to a ventilator and the epidural catheter was removed. The next day she underwent craniotomy with only partial removal of rapidly growing tumor. In the postoperative period the treatment of her persistent increased intracranial pressure was unsuccessful. Two day after surgery she was declared brain dead and care was subsequently withdrawn. Summary: There are no guidelines for the optimal time for craniotomy in the pregnant patient with intracranial tumor. Neurosurgery is usually delayed until after delivery. In our case, upon insertion of the epidural catheter, there was no clinical evidence of increased intracranial pressure. We still made every effort to reduce the risk of accidental dural puncture by performing the block in lateral decubitus position, reinserting the stylet upon each advancement of the needle, administering the local anesthetic by gravity technique and applying Arrow catheter. The aggressive nature of the tumor caused this bad outcome. We suggest that epidural block may still be a viable option for parturients with intracranial tumors and normal ICP admitted for labor and delivery. References: 1. Cohen S, et al. Anesthesiology 2003; 99:A1161. 2. Cohen S, et al. Clin Anesth 1997; 9:623-628. A241 GABAPENTIN FOR CHRONIC REFRACTORY NEUROPATHIC PAIN SECONDARY TO NEUROBORRELIOSIS A. Solanki, J. Nagda Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA Introduction: Persistence of pain even after appropriate treatment of neuroborreliosis is potentially a severe and debilitating complication of Lyme disease. Both, the etiopathogenesis and management of this refractory pain are not well defined. Case reports of successful treatment of the painful component of neuroborreliosis are lacking in literature. We describe a rare case of refractory painful neuroborreliosis successfully treated with gabapentin. Case presentation: A 68 year old male resident of Connecticut with no significant past medical history was admitted to the hospital with 4 weeks history of progressive torso numbness, back pain radiating to the legs, and proximal leg weakness. This lower extremity weakness rapidly progressed to paraplegia which was present upon arrival to the hospital. Pain was poorly controlled with NSAIDs. There was no history of tick bite or any rash in the recent past. No history of fever, dysuria, trauma, headache, bladder or bowel incontinence was noted.His vitals were stable. Clinical exam revealed lower extremity motor deficit with absent tendon reflexes and babinski reflex. Rest of the exam was unremarkable. Routine laboratory evaluation was non contributory. Magnetic resonance imaging (MRI) of back and Computed tomography (CT) of head and abdomen did not reveal any abnormality. ELISA for Lyme antibodies (Ab) was positive which was then confirmed with positive serum IgM and IgG Lyme Ab by Western Blot. The patient was diagnosed with neuroborreliosis. After 3 weeks of ceftriaxone therapy, his flank and groin pain resolved along with complete resolution of paraplegia. He was discharged home with opioids for persistent back pain.The patient presented to the Pain Center after 3 weeks of failed trial of opioids with intense pins/needles sensation in T8-T12 dermatomal distribution and significant hyperhydrosis on the affected dermatomes. Physical exam revealed thoracolumbar neuropathy. The clinical presentation and physical exam findings were suggestive of an inflammatory radiculopathy which was most likely due to Lyme disease. Given the neuropathic model of pain, patient was initially prescribed gabapentin 100 mg daily. Within 3 weeks of escalating doses of gabapentin, his painful radiculitis completely resolved. Till date, his pain is well controlled with gabapentin. Discussion: Lyme disease is the most frequently reported arthropod borne infection of nervous system in Europe and USA. Neuropathic pain persists in 10-15% cases of neuroborreliosis even after 1 adequate treatment . Pain is usually refractory and no recommendation is available for its treatment. Our patient was given gabapentin in escalating doses with complete resolution of symptoms over 3 weeks. Our experience with this case indicates that gabapentin may be tried as the first agent in this situation. Further studies are required for studying the treatment of refractory neuropathic pain of neuroborreliosis. References: 1. Weissenbacher S, Ring J, Hofmann H. Gabapentin for the symptomatic treatment of chronic neuropathic pain in patients with late-stage lyme borreliosis: a pilot study. Dermatology. 2005;211(2):123-7. A242 COLOR DOPPLER GUIDED CONFIRMATION AND LOCALIZATION OF EPIDURAL CATHETER A. Sonny, S. Mohamed, H. Elsharkawy Anesthesiology, Cleveland Clinic, Cleveland, OH, USA Introduction: Epidural analgesia is a widely used neuraxial method for postoperative analgesia. Traditionally, loss of resistance (LOR) to air or saline is used to identify epidural space. However, primary failure rate can exceed 10%. Thoracic paravertebral spaces, gaps in ligamentum flavum and muscle layers can lead to false LOR and subsequent inaccurate placement of epidural catheter. Although clinical response to local anesthetic in the form of dermatomal anesthesia is the “gold standard” to correct placement, it takes time to elicit and could be difficult to perform in a patient who has received sedation for the procedure. Here we describe a novel technique using color Doppler to confirm and identify position of the catheter in the epidural space. Case: We present a 65 year old male patient, scheduled for preoperative placement of lower thoracic epidural catheter for upcoming exploratory laparotomy. Patient approval was obtained for presentation. We anticipated difficulty in epidural placement due to inability to reliably identify landmarks, due to excess subcutaneous fat and also moderate scoliosis identified by X-ray. Using 2-5 MHz curvilinear ultrasound probe, we identified the landmarks and the depth from skin to the duramater. Using the paramedian oblique sagittal view and in plane needle insertion, an echogenic 18 gauge Touhy needle was advanced into the T8-9 interspace under real time ultrasound guidance. Epidural space was identified utilizing loss of resistance to saline. Subsequently, epidural catheter was easily advanced into the epidural space through the needle. About 5 cm of the catheter was left in the space. Color Doppler Ultrasound images were obtained, in the paramedian sagittal oblique view, at the level of insertion of the epidural catheter, while injecting saline through the catheter. We were able to identify the path of the catheter from the skin to its entry into the epidural space, thus confirming its correct placement. [Image 1] Further images were obtained above and below the insertion point. The flow of saline, signifying the path of the catheter, could be easily identified within the epidural space. [Image 2] This provided us information on the path of the catheter inside the epidural space and potentially location of the catheter tip. Discussion: Various methods have been described in literature to confirm and localize the position of epidural catheter after placement. These include epidural stimulation test, epidural pressure waveform analysis and injecting dye with fluoroscopic confirmation. These are cumbersome to perform in a perioperative setting and lack sensitivity, and thus have not gained popularity. Ultrasound has been described to look at the spread of the local anesthetic in the epidural space, by monitoring the movement of dura as the epidural space expands. But these are difficult to obtain at the thoracic level especially in the adults. With the easy availability of ultrasonography in most regional anesthesia settings, color Doppler imaging could be a quick and easy way to confirm position and follow path of the catheter in epidural space. A243 JUST ANOTHER NERVE BLOCK... R. Sreedharan, H. Elsharkawy, W. Ali Sakr Esa Cleveland Clinic Foundation, Cleveland, OH, USA Eventration of diaphragm is an abnormally high position of part or the entire diaphragm, usually associated with a marked decrease in muscle fibers and a membranous appearance of the abnormal area. Majority of the adult patients with eventration of the diaphragm are asymptomatic. We describe a case of a patient who had an asymptomatic eventration of the left diaphragm and received a supraclavicular nerve block for a shoulder surgery on the right and developed acute respiratory compromise. 79 year old male with a significant past medical history of CAD, was scheduled for a right sided reverse shoulder arthroplasty. He did not have a history of any respiratory symptoms. Preoperatively a right supraclavicular(SC) nerve catheter was inserted under ultrasound guidance using a 17 G tuohy needle. A total of 14 cc of local anesthetic (7cc 2%mepivicaine+7 cc 0.5% ropivicaine) was given through the catheter. Towards the end of the procedure, the SC catheter infusion was started with ropivicaine 0.2% basal rate of 8 cc, demand dose of 12 cc every 60 minutes. Few minutes after extubation there was desaturation to the mid 80's. Hemodynamics were stable. The differentials at this point included postoperative atelectasis, myocardial ischemia, fluid overload or phrenic nerve palsy due to the SC nerve block. The SC infusion was stopped and he was transferred to the post anesthesia care unit. A CXR showed a significant pleural effusion on the right side. Postoperative EKG and cardiac enzymes were normal. Diaphragmatic function assessment at the bedside was done using an ultrasound. There was a significant restriction of diaphragmatic movement on the right side. Of note the left side diaphragmatic movement was significantly restricted as well (Images below) Right side - midclavicular line - No pneumothorax. M mode - restricted diaphragmatic movement with quiet breathing [USG image- right side of diaphragm ] Left side- anterior axillary line . M mode- restricted diaphragmatic movement with sniffing and quiet breathing [USG image- left side of diaphragm] On review of his older records his CXR from a year ago did mention the presence of eventration of his diaphragm on the left which the patient was not aware of. There were multiple episodes of desaturation over the next day in spite of attempts to restart the infusion at a lower rate. Evaluation during these episodes revealed desaturation with hypercapnia. Hence the decision was made to remove the catheter. There were no more episodes of respiratory compromise. The SC approach is associated with phrenic nerve palsy in 63% of the patients. In our patient, in the presence of an impaired diaphragmatic function on the left due to eventration, a right sided brachial plexus block with phrenic nerve involvement mostly probably caused his respiratory compromise. In conclusion, a preoperative or postoperative ultrasound assessment of the diaphragm before doing a brachial plexus block could be fairly simple, quick and could possibly avoid a potentially fatal complication. Verbal consent has been obtained from the patient for this presentation A244 CONTINUOUS EPIDURAL ANESTHESIA AS THE PRIMARY ANESTHETIC FOR MODIFIED RADICAL MASTECTOMY IN A PATIENT WITH PULMONARY FIBROSIS A.T. Tantoco, D. Elmofty Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA Introduction: Restrictive lung disease is a known risk factor for post-operative pulmonary complications in patients who undergo a general endotracheal anesthetic technique. Continuous epidural anesthesia and analgesia is known to support improved pulmonary mechanics when compared to general anesthetic techniques. More recently, anesthetic technique may also have an effect on breast cancer recurrence. Here, we report a case of a patient with extensive pulmonary fibrosis undergoing mastectomy for newly diagnosed breast cancer, the second in our case series of mastectomies performed using continuous thoracic epidural anesthesia. Case report: The patient was a 50 year old female who presented for modified radical mastectomy and axillary lymph node dissection for intraductal carcinoma. She had a history of fibrotic lung disease felt to be secondary to mantle radiation and bleomycin toxicity for Hodgkin's lymphoma several years prior. At baseline, she used nocturnal supplemental oxygen and experienced dyspnea after walking up one flight of stairs. Pre-operative PFTs displayed decreased FEV1 and FVC (34% and 37% predicted, respectively). Given the high risk of pulmonary complications of a general endotracheal anesthetic, the procedure was performed using continuous thoracic epidural anesthesia with monitored anesthesia care. A 17 G Tuohy needle was inserted with the aide of fluoroscopy in the T45 epidural space using a L paramedian technique with loss of resistance at 3.5 cm. An epidural catheter was then threaded to the T2-3 interspace and the tip position was confirmed with an extradural myelogram demonstrating appropriate epidural spread. 1.5% lidocaine with 1:200,000 epinephrine was administered through the epidural catheter intermittently throughout the procedure; an intravenous infusion of 10:1 propofol/ketamine was used for sedation. Discussion: Epidural anesthesia and analgesia has many advantages including improving postoperative VC and FRC and reducing the rate of postoperative pulmonary complications. In a metaanalysis including 141 randomized trials with almost 10,000 patients, Rodgers et al described a reduction in post-operataive pneumonia by 39% and a reduction of mortality of about one third when compared to a systemic analgesic regimen. In addition to the advantages of improved decreased pulmonary morbidity, recent interest has described the possible effects of anesthetic technique in relation to the pathophysiology of malignancy. General anesthesia and opioid analgesia, by transient alterations in the immune system, may potentially increase the incidence of cancer recurrence. Deegan CA et al described how patients receiving propofol/paravertebral anesthesia for breast cancer surgery significantly inhibited the proliferation of an ER-negative cell line in vitro as well as altering both pro- and anti-tumorigenic cytokines in comparison to those patients who received a sevoflurane/opioid anesthetic. References: Rodgers A et al (2002). Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. Br Med J 321:1-12 Deegan CA et al (2009). Effect of anaesthetic technique on oestrogen receptor-negative breast cancer cell function in vitro. BJA 10 (5) 685-90. A245 ULTRASOUND GUIDANCE FOR BILATERAL SUPRACLAVICULAR BLOCK IN A PATIENT WITH ELECTROCUTION INJURY: CASE REPORT P.R. Telang, B. Gelpi, C.G. Samuelson, S. Billiodeaux, J.D. Adair Anesthesiology, Louisiana State University, Shreveport Health System, Shreveport, LA, USA Introduction: Electrocution injuries are unique due a to low mortality, but a significant short and long term morbidity(Hussmann). Neurological complications are common due to the initial death of the nerve cells, and fibrosis of the remaining nerve tissue. Damage to inhibitory neurons and growth of excitatory afferent neurons leads to the development of neuropathic symptoms, and increases the possibility of the developing chronic pain syndrome(CPS)(Searle). Controlling pain is a priority both for management of acute pain and for reducing the risk of developing CPS. This study describes the utility and clinical considerations of ultrasound guidanced(US) placement of bilateral supraclivular catheters for pain control in a patient with electrocution injury. Case description: A 29 year old man suffered bilateral upper extremity injuries after grabbing a high voltage power line. Severe tissue damage along with sensory and motor deficits in both upper extremities, andwith wounds in both axilla. necessitated bilateral below elbow amputations. His postoperative course was complicated by pain refractory to IV narcotics. Initial attempts at brachial plexus blockade were unsuccessful via nerve stimulation technique(NS). Due to the high rate of phrenic nerve paralysis with interscalene blocks, we decided to place bilateral supraclavicualr catheters using US. After discussing the risks and benefits, a left supraclavicular block was performed. The patient was monitored for relief of symptoms and complications. Due to continued pain, this procedure was repeated on the right with similar monitoring. This efectively controlled the patient´s pain. The remainder of his hospitalization was uneventful. Discussion: Supraclavicular nerve blocks can be performed by eliciting paresthesia, NS, or US(Mirza). The first two techniques may not be reliable in identifying the brachial plexus due to extensive nerve damage caused by electrical trauma. Prior attempts using NS for placement were unsuccessful despite increasing the current level. Furthermore, our patient had bilateral below elbow amputations which complicated anatomical correlation to the twitch response. US allows real-time visualization of the anatomy and has been shown to be associated with superior rates of block success, physician confidence and lower rates of complication(Abrahams,Yuan) This case highlights the need for acute pain control in patients with electrical injury. In addition it defines a group of patients in whom NS blockade may not be possible. Finally it stresses the potential complications of bilateral blockade and the need for patient monitoring. Conclusion: Pain control in patients with electrocution injuries can prove difficult. Traditional approcahes at nerve blockcade may not be possible, and as such US should be considered. All patients undergoing continuous blockade should be monitored for complications. References: - Hussmann J, et.al. Electrical injuries--morbidity, outcome and treatment rationale. Burns.1995 Nov;21(7):530-5 - Searle, RD, Simpson KH. Chronic Post Surgical Pain. Continuing Education in Anaesthesia. Critical Care and Pain. Vol 10 Number 1 2010 - Mirza F, et al. Ultrasound-guided regional anesthesia for procedures of the upper extremity. Anesthesiol Res Pract. 2011. Epub 2011 May 30. - Abrahams MS, et al. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009 Mar;102(3):408-17. A246 THE USE OF REGIONAL BLOCK IN A PATIENT WITH PHANTOM LIMB PAIN A. Tharian, S. Klier, K.D. Candido, N.N. Knezevic 1 2 Anesthesiology and Pain Medicine, Advocate Illinois Masonic Medical Center, Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Introduction: The reported prevalence of phantom pain varies widely in the literature, but today most 1 studies agree that 60% - 80% of all amputees experience phantom pain following loss of limb. Despite extensive research in the area, the mechanism underlying phantom limb pain is not fully known and its treatment remains a major challenge to pain management clinicians. Case description: A healthy 68-year-old female developed progressive left shoulder pain over 2 years, which was attributed to a rotator cuff tear. However, surgical arthroscopy identified a mass lesion and biopsy specimen reported myoepithelioma of the bone affecting the shoulder joint. A left forequarter amputation was done under general anesthesia and an interscalene nerve block using 30 mL of 0.5% Ropivacaine for post operative analgesia was performed. She developed persistent excruciating pain of left arm and forearm, 8-10 hours after the sensory block dissipated. At POD #1 she developed a “crushing sensation” in the non-existent left hand. Amitriptyline, Gabapentin, Oxycontin and Fentanyl patches failed to minimally control pain. Analgesic medications failed to provide longer than 6-8 hours pain relief. Supraclavicular nerve block was done under ultrasound guidance with 20 ml of 0.2% Ropivacaine by using an insulated 5 cm Pajunk needle. The numeric pain score dropped from 10/10 to 2/10 after the supraclavicular block and remained at this level for 72 hours, after which it gradually increased to 4/10, but not higher. She was able to discontinue use of Amitriptyline and Gabapentin, and to wean gradually off of the Fentanyl patch therapy. Conclusion: No single therapy has been found to be uniformly effective for the successful treatment for phantom limb pain and multiple treatments maybe combined in a true multi-modal fashion to achieve the optimal result. This case report proposes a timely implementation of a brachial plexus regional nerve block as one of the interventional therapies which can be considered for upper extremity phantom pain relief. Reference: 1. Birbaumer, N. et al. Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical reorganization J Neurosci 1997;17: 5503-8. A247 A CASE OF WINGED SCAPULA FOLLOWING THE PLACEMENT OF AN INTERSCALENE PERINEURAL CONTINUOUS CATHETER S.E. Thomas, E. DeBusk, J.B. Winchester, G.V. Hickman 1 2 Regional Anesthesia Fellowship, BLOCKJOCKS Research and Education Foundation, The Andrews Institute ASC, Gulf Breeze, FL, USA Introduction: As an ambulatory surgery center, we perform interscalene catheters for shoulder surgery. To minimize the possibility of phrenic nerve blockade we employ a posterior approach and in combination with a low volume technique, we have observed a significant decrease in the incidence of postoperative respiratory complications while maintaining a nearly 100% success rate for postoperative analgesia. We feel that traversing the middle scalene muscle provides a relatively unobstructed path to the posterior aspect of the cervical roots within the interscalene groove and avoids many of the vital structures encountered with an anterior approach including the phrenic nerve itself, the carotid artery, and the internal jugular vein. We are unaware of any outcome data that supports injury to the dorsal scapular and long thoracic nerves related to an interscalene block. We have a challenging case of a patient who suffered long thoracic nerve injury following shoulder surgery, presumably as a result of interscalene catheter placement. Materials and methods: The patient underwent a right rotator cuff repair with subacrominal decompression and bicep tendon repair. Her preoperative assessment demonstrated shoulder pain but no significant motor or sensory deficits in her upper extremity.On the day of surgery, an experienced anesthesiologist uneventfully placed in pre op an interscalene catheter using ultrasoundguidance (without concomitant nerve stimulation)under midazolam sedation.Her surgery and PACU stay were uneventful and she was discharged home with the indwelling catheter and elastomeric pump.She remained comfortable and denied any adverse symptoms for as long as the catheter remained in place. She removed the catheter on post-operative day 3 without difficulty. During her routine two week postoperative visit with the surgeon she was noted to have significant shoulder weakness, poor scapular stabilization and significant medial scapular winging on the right side only. She was felt to have had good operative result and was referred for further evaluation by a physiatrist. Results: The EMG study demonstrated severe incomplete right long thoracic neuropathy. Although her prognosis is good for regaining most or all of her strength and function her neurologic recovery is expected to take between 18 and 20 months and she will need to undergo rehabilitation for several months. Discussions: We were unable to identify any other confirmed cases of nerve block-related long thoracic or dorsal scapular nerve injuries in the regional anesthesia literature. It remains unclear to us whether the addition of nerve stimulation to the use of ultrasound would effectively reduce the likelihood of injury to these nerves by allowing safe needle redirection if long thoracic or dorsal scapular nerve twitch is elicited absent ultrasound visualization during needle passage. One could argue that systematic ultrasonographic +/- nerve stimulator assisted identification of these nerves, or at the very least awareness of their presence, could help avoid adverse outcomes such as this one. References: Hanson N, Auyong D,Systematic Ultrasound Identification of the Dorsal Scapular and Long Thoracic Nerves During Interscalene Block, Regional Anesthesia & Pain Medicine. 38(1):54-57, January/February 2013 Conflict of Interest: Debusk-BBraun Medical Winchester-BBraun Medical, Kimberly Clark, Pacira Hickman-BBraun Medical, Kimberly Clark, Pacira The patient consented / IRB approved. A248 AN ATYPICAL RESPONSE TO INTRATHECAL BACLOFEN LIMITS THE THERAPEUTIC OPTIONS FOR THE MANAGEMENT OF A PATIENT WITH SPASTICITY RELATED PAIN: A CASE REPORT B.F. Thompson, M.W. Christopherson Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA Case description: A 34 year-old women with a past medical history significant for a slowly progressive spastic paraparesis secondary to chorionic myelopathy presented for management of painful spasms. She had failed previous treatment with oral Baclofen and Zanaflex. Physical exam revealed scissoring gait pattern, 4+/4+ lower extremity reflexes, bilateral non-sustained clonus, and Modified Ashworth Score of 2 at her bilateral ankles and knees and 3 at her hips. An intrathecal test dose bolus injection of baclofen was scheduled in hopes that she may have success with implantable pump system. She underwent a fluoroscopically-guided intrathecal baclofen test dose injection of 75 mcg bolus given over 3 minutes at the L3-L4 level using a 20-gauge spinal needle. Thirty minutes following the procedure she developed an acute 10/10, holocephalic headache and nausea without decrement from the upright to supine position. Neurologic examination remained unchanged with the exception of improved lower extremity tone. Her headache slowly improved over the subsequent five days. The immediate onset and nature of her pain, unaffected by change in position, was inconsistent with a diagnosis of a post-dural puncture headache. It was, instead, concluded that she had primary intrathecal baclofen insensitivity. Repeating the injection at a reduced dose could have confirmed this diagnosis since her symptoms would be expected to recur in a dose-independent fashion. However, our clinical suspicion was high enough not to justify the potential discomfort of a second injection. Instead, an alternative management strategy was pursued. Discussion: It is well known that intrathecal baclofen bolus injections can cause spinal headaches and lower seizure thresholds, leading to acute neurologic sequelae. The literature finds that up to 10% of patients with intrathecal baclofen pumps report intermittent headaches; however, these are generally described as mild and are associated with other common symptoms of hypotonia and somnolence suggesting a dose-dependent effect. To our knowledge, this is the first documented case of an acute post-procedure headache secondary to primary baclofen insensitivity. Conclusion: Medication insensitivities can be easily confused with procedure-related symptoms, particularly given that post-dural headaches are relatively common. It is important to consider the timing and quality of the patient's symptoms. If the clinical signs suggest medication insensitivity, a second test dose should be avoided to prevent unnecessary discomfort. A249 REDUCTION OF TEMPOROMANDIBULAR JOINT DISLOCATION WITH KETAMINE 1 1 1 2 S.K. Tuncer , U. Kaldirim , M. Toygar , E. Eyi , M. Durusu 1 2 1 3 Emergency Medicine, Forensic Medicine, Gulhane Military Medical Academy, Ankara, Emergency Medicine, Hakkari Military Hospital, Hakkari, Turkey Introduction: Temporomandibular joint (TMJ) dislocations take place among Maxillofacial Emergencies. Translation and rotation is achieved by articulation of mandibular condyle with temporal bone in the mandibular fossa. These two bones are separated by an articular disc. In most intances, the disc is displaced anteriorly (1). More commonly, dislocation occurs bilaterally and radiographs or CT may be necessary for diagnosis (2). In the treatment of patients with no other clinical findings suggestive of fracture, reduction is adequate. Reduction is achieved by grasping mandible with both hands and resting thumbs inside the mouth on the molars, then applying downward and backward (1). Analgesia, muscle relaxation, local anesthesia and sometimes sedation are advised to promote successful manual reduction (3). These cases highlight the importance of providing the patient with adequate sedation with Ketamine when attempting the reduction of TMJ dislocations. Case 1: 21-year-old patient with jaw pain and limited movement due to a punch stroke was admitted to emergency department. Physical examination revealed limitation of movement of jaw, tenderness, spasm, and deformity in TMJ. Radiologic assay revealed bilateral temporomandibular anterior dislocation. Instead of reduction, procedural sedation was performed because of patients' lack of orientation, spasm and pain. After providing adequate sedation with intravenous Ketamine 70mg; reduction was successfully performed at a time. Patient was discharged after follow-up. Case 2: 28-year-old woman was presented with jaw pain and limited movement of jaw due to trauma. Physical examination revealed limitation of movement of jaw, bilateral TMJ tenderness, pain. Radiologic assay revealed bilateral temporomandibular anterior dislocation. Because of patients' agitation and pain; reduction wasn´t performed. After monitorization with the help of Ketamine 55mg administration; adequate sedation was achieved. Reduction was performed with success in a short time. Patient was discharged after follow-up. Discussion: Reduction of TMJ is generally achieved by applying downward and backward pressure on patient´s lower molar teeth. Coordination and adaptation problems due to pain and agitation are the inhibiting factors for reduction. Troubling reductions and recurrent unsuccessful attempts for reductions may result in deformity of TMJ. Reduction is unlikely to be successful without adequate analgesia and sedation due to pain or agitation. Therefore analgesia and sedation are advised to promote successful manual reduction. Agent of choice includes Ketamine if there isn´t any contraindication (6). We suggest fingers should be gloved with adequately thick gauze taped securely on both thumbs to prevent injury. References: 1. Chan TC, Harrigan RA, Ufberg J, Vilke GM. Mandibular reduction. J Emerg Med. 2008 May;34(4):435-40. 2. Brooks SL, Brand JW, Gibbs SJ, et al: Imaging of the temporomandibular joint: a position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83: 609, 1997. 3. Andrew L. Y, Junad K, Davis C. T. Samuel Y. P. Q. Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation. Anesth Prog 56:9-13 2009 4. Reuben J. Strayer MD, Lewis S. Nelson MD, Adverse events associated with ketamine for procedural sedation in adults, AJEM (2008) 26, 985-1028 A250 CONTINUOUS SPINAL ANESTHESIA AND STREAMING MOVIE FOR A PATIENT WITH MULTIPLE COMORBIDITIES UNDERGOING VASCULAR SURGERY O. Viktorsdottir, J.E. Charnin, R.M. Allain 1 2 Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Department of Anesthesiology, St. Elizabeth's Medical Center. Tufts University, Boston, MA, USA Introduction: We report a case of an elderly man with occlusive vascular disease, critical aortic stenosis, pulmonary hypertension and unstable cervical spine fracture undergoing an attempted femoral-popliteal bypass graft. The accommodation for hemodynamic and airway issues produced the complexity of this case. Case report: An 87 year old ASA Class 4 patient with history of hypertension, hyperlipidemia, coronary artery disease with 4 BMS placed 7 months ago, severe aortic stenosis awaiting percutaneous transcatheter aortic-valve replacement, severe pulmonary hypertension, atrial fibrillation, insulin dependent diabetes and significant history of anxiety and agitation with procedures, presented for right femoral-popliteal bypass graft for non-healing leg ulcer. A transthoracic percutateous aortic valve replacement was deemed unsafe given high risk for infection while his nonhealing right leg ulcer persisted. The patient refused amputation of the leg as recommended by the vascular surgeon and wished to proceed with a high-risk attempt of revascularization of his right leg. The night before the scheduled surgery, the patient sustained a fall resulting in an unstable cervical fracture of C1 and C2. The patient was not deemed a candidate for fixation due to his poor cardiovascular health and conservative management with Aspen collar for 8 weeks was recommended. The surgery was rescheduled two weeks after the neck fracture and the patient underwent an attempted right femoral popliteal bypass graft under continuous spinal anesthesia. The spinal catheter placement was challenging because of scoliosis but was successful in the sitting position. We used a mixture of 0.1% bupivacaine and 1.5% mepivacaine. Operative conditions were excellent. A central line was placed before the start of the spinal anesthetic and low dose norepinephrine infusion was used intraoperatively to maintain SVR. No additional sedatives or narcotics were administered. To distract the highly anxious patient, a movie of patient's choice was streamed to an iPad supported in a position above the patient's chest with a metal stand mounted to the bed with a Clark Adapter. The patient remained hemodynamically stable throughout the case. Unfortunately, revacularization was not technically possible and the patient returned 3 days later for below-knee-amputation where the same anesthetic technique was again successfully used with the addition of intrathecal morphine for postoperative pain control. Discussion: We report a case of a vascular patient with multiple comorbitites undergoing an attempted femoral-popliteal bypass graft. The patient presented a number of anesthetic challenges which lead to an anesthetic plan of continuous spinal anesthesia. Instead of administering sedatives for monitored anesthesia care, we successfully managed to stay away from sedatives altogether by streaming a movie to an iPad, mounted above patient's chest. A251 SUBCUTANEOUS BOTULINUM TOXIN A INJECTION FOR TREATMENT OF A CASE OF FACIAL POST-HERPETIC NEURALGIA P. Vu, S. Jones Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA Introduction: Post-herpetic neuralgia (PHN) is a pain condition caused by the herpes zoster virus that typically presents in a dermatomal distribution. It has been conventionally treated with an array of medications including anticonvulsants, antidepressants, opioids, and topical lidocaine and capsaicin. We present a case of significant pain relief of PHN with Botulinum Toxin A (BTX-A). Case description: A 64 year old female with a past medical history of hypertension and diabetes mellitus type II presented for treatment of 10 month history of PHN in the right V3 (mandibular) distribution. Pain was 8-10/10 on a Visual Analog Scale (VAS). Allodynia was noted along the right lower face and tongue in the V3 distribution. The patient had been trialed on multiple anticonvulsants, antidepressants, opioids, non-steroidal anti-inflammatories, muscle relaxants, and topical ointments with minimal relief. Based on the clinical presentation and failed trials of multiple medications, BTX-A was trialed. BTX-A was reconstituted at 100 units with 20 mL of normal saline to a concentration of 5 units/mL. A grid of 2x2 cm squares was drawn and 1 mL of BTX-A was injected aseptically at each 2x2cm target with a 30 gauge 0.5 inch needle. Eighty units of BTX-A were injected among 16 sites. At one month, significant pain relief was reported with VAS of 3/10 with improved mood and functionality. She did have mild right buccal weakness and persistent pain in the right tongue, which was not injected due to risk of dysphagia. Her pain returned in severity approximately 3 months after the injection. Discussion: PHN is a pain condition that affects between 5-20% of people following an outbreak of herpes zoster. Several medications have been used to treat PHN with no single best therapy emerging. Though BTX-A has been used for treatment of migraine headaches and dystonias, few reports and studies have cited the use of BTX-A for alleviation of PHN. BTX-A is thought to have both peripheral and central anti-nociceptive effects through inhibiting release of glutamate, substance P and calcitonin gene-related protein. Our patient exhibited significant pain relief after BTX-A with improved function and mood lasting for 3 months. BTX-A appears to be a promising therapy for the treatment of PHN. Further reports and studies are needed to confirm the efficacy of this emerging therapy for treatment of facial PHN. References: · Xiao L, Mackey S, Hui H, Xong D, Zhang Q, Zhang D. Subcutaneous Injection of Botulinum Toxin A is Beneficial in Postherpetic Neuralgia. Pain Med 2010 Dec;11(12):1827-33. · Liu HT, Tsai SK, Kao MC, Hu JS. Botulinum Toxin A Relieved Neuropathic Pain in a Case of PostHerpetic Neuralgia. Pain Med 2006;7:89-91. A252 A CASE OF ISOLATED FEVER WITH CONTINUOUS EPIDURAL ANALGESIA IN A NONOBSTETRIC SURGICAL PATIENT P. Vu, J. Kweku, G. Cheng Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA Introduction: Isolated fever with continuous epidural analgesia has been well documented within the obstetric population. While some mechanisms have been proposed, no exact process has been identified as the source of these fevers. It is thought that hypothermia occurs with epidural analgesia in the non-obstetric patient. We present a case of isolated fevers from epidural analgesia in a nonobstetric surgical patient. Case description: A 57 year old Caucasian female with past medical history of pancreatic cancer undergoing a pancreaticoduodenectomy presented for a preoperative low-thoracic continuous epidural for post-operative pain control. The epidural space was identified at the interspace between th th the 8 and 9 vertebrae by loss of resistance technique with air and an epidural catheter was placed atraumatically with negative test dose for intravascular or intrathecal placement. The epidural was bolused with 0.25% bupivacaine and the epidural infusion was started intraoperatively. The patient had an uneventful intraoperative course and was taken to the intensive care unit extubated for closer monitoring. Four hours after the end of surgery, and twelve hours from epidural placement, the patient was found to have a temperature of 38.6 degrees Celsius. She had no tachycardia, tachypnea, or leukocytosis. The patient continued to have fevers on post-operative day (POD) #1 without any other signs or symptoms of infection. Her pain was well controlled and she had no complaints. Although suspicion was low, blood and urine cultures were sent to rule out infection. The patient continued to have isolated fevers with temperature peaking at 39.3 on POD #2 still with no leukocytosis, bandemia, tachycardia, or tachypnea. Cultures showed no growth and chest x-ray did not show any infiltrates or consolidation. The source of the fever was thought to be due to the epidural as no other source could be identified. Decision to remove the epidural was made between the surgical and acute pain services. The epidural was removed without issue. After epidural removal, the patient's body temperature decreased to 36.9 within two hours. She continued to have core body temperatures within normal range throughout the rest of her hospital course with all final cultures being negative. Discussion: Epidural-related fever in the obstetric patient has been well documented with evidence supporting maternal inflammatory response from increased pro-inflammatory cytokines. Other proposed mechanisms include alterations in the thermoregulatory pattern, sympathetic stimulation, and oxidative stress. Traditionally, epidural analgesia is thought to cause hypothermia, not hyperthermia in the surgical patient due to sympathectomy-related vasodilation with redistribution of body heat to the peripheral tissues. However, increased inflammatory response could potentially explain our patient's fevers in the absence of infection. Our patient exhibited steady temperature elevation post epidural placement with a peak temperature of 39.3 degrees Celsius. After removal of the epidural catheter, the patient had a return to normothermia within a few hours further supporting the belief that the fevers were related to the epidural. Further research is warranted. References: - Epidural analgesia and maternal fever: a clinical research update. Curr Opin Anaesthesiol. 2012 - Labor Epidural Analgesia and Maternal Fever. Anesth Analg 2010 A253 EVALUATING THE FEASIBILITY OF TAP BLOCK AS A PRIMARY ANESTHETIC TECHNIQUE FOR LAPAROTOMY IN HIGH RISK PATIENTS J.T. Vuong, S.D. Adhikary, P. McQuillan, E. Messaris 1 2 Anesthesiology, Colorectal Surgery, Penn State Hershey Medical Center, Hershey, PA, USA The anesthetic management of elderly patients undergoing abdominal surgery is focused on minimizing morbidity and mortality. The physiological changes of aging, in addition to preexisting comorbidities, necessitate maintaining hemodynamic stability, avoiding hypoxia, and aggressive pain management. The risk of prolonged intubation favors avoiding airway compromise. Although PCA and epidural analgesia are useful, they may be contraindicated or technically difficult. Parenteral opioid administration has been associated with delirium. We present three cases utilizing transversus abdominis plane (TAP) block as the primary anesthetic for laparotomy. In the operating room, standard ASA monitors and nasal cannula oxygen were applied. Blocks were performed after sterile prep and draping using only midazolam and fentanyl for sedation. A real-time technique utilizing in-plane ultrasound visualization was used. Case 1: A 92 year old, 64kg woman with sigmoid cancer status post loop colostomy presented with ostomy prolapse. Her comorbidities included hypertension, carotid disease, previous postoperative stroke, and coronary artery disease. Medications included a statin, beta blocker, and aspirin. A TAP block was performed with injection of 40mL of 0.25% bupivacaine in divided doses. During the 1.5 hour surgery, she received 20-25 mcg/kg/min propofol. Surgeons resected 60 centimeters of bowel and created an end colostomy and mucous fistula. Case 2: A 66 year old, 115kg man was transferred from an outside hospital on vasopressors for hypotension during an ulcerative colitis flare. His comorbidities included multivessel CAD, severe heart failure, AICD for ventricular tachycardia, obstructive sleep apnea, GERD, anemia, and an aortic aneurysm. Medications included chronic steroids, beta blocker, aspirin, and nitrates. His preoperative course was complicated by a hospital acquired pneumonia, bilateral pulmonary emboli, and GI bleed after heparinization. A TAP block was performed with injection on each side of 30mL of 0.25% ropivicaine and 1% lidocaine in a 50/50 mix. He received no further sedation during the 1.5h loop ileostomy surgery. Case 3: A 91 year old, 70kg woman was admitted with gastrointestinal bleeding. Her comorbidities included atherosclerotic heart disease, valvular dysfunction, AV block, renal insufficiency, hypertension, and Parkinson's disease. Medications included clopidogrel, aspirin, calcium channel blocker, beta blocker, nitrates, and anti-Parkinson drugs. A TAP block utilized 40mL of 0.25% bupivacaine injected in divided doses. During the 3 hour resection of a large cecal adenocarcinoma, she received 100mcg of fentanyl and 25mcg/kg/min propofol. 1,2 Mortality for elderly patients undergoing emergency abdominal surgery is significant . Comorbidities, time from symptom onset to surgery, colorectal surgery, age >80, and malignancy correlate with 2 increasing mortality. Morbidity is highest for the respiratory system (11.5%). We have demonstrated the efficacy of a TAP block as a surgical anesthetic, avoiding airway manipulation and hemodynamic instability that might accompany induction. Our block placement required < 30 minutes and one attempt per patient, by residents as well as an attending anesthesiologist. All patients remained stable intraoperatively. References: 1. Jin, F, Chung, F. “Minimizing perioperative adverse events in the elderly.” Br. J. Anaesth. 2001 87 (4): 608-624. 2. Arenal, Juan, BengoecheaBeeby, M. “Mortality associated with emergency abdominal surgery in the elderly.” Can J Surg. 2003 April; 46(2): 111-116. A254 DIAGNOSTIC AND THERAPEUTIC OCCIPITAL NERVE BLOCKS FOR REPORTED TRAUMA INDUCED OCCIPITAL NEURALGIA J. Walker, S. Howell 1 2 Anesthesia, WVU Healthcare, Morgantown, WV, USA Chronic headaches can be debilitating for many patients. Headache disorders often have a nebulous etiology, unpredictable course, and can be difficult to manage. We describe a post-traumatic headache that began after a motor vehicle collison. The patient sustained multiple injuries including a scalp laceration and bilateral occipital condyle fractures. Oral agents were unable to quell this patient's headaches. The diagnosis of occipital neuralgia was suspected based on history and the patient received dramatic relief after ultrasound guided bilateral occipital nerve blocks. Case Presentation: A 45 year old, 127 kg male was hospitalized following a motor vehicle accident. He struck a tree while driving home from work and sustained multiple injuries including traumatic ventral hernia, traumatic left testicular hematoma, open bilateral superior and inferior pubic rami fractures, scalp laceration, nasal bone fractures, and bilateral occipital condyle fractures. During his four week hospital stay, the headaches became more frequent and severe. His past medical history was only remarkable for type II diabetes mellitus. Hospital medications consisted of Xanax, Cymbalta, MS-Contin, Percocet, Flexeril, Ultram, metoprolol, simvastatin, and metformin. The headaches were characterized by sharp pain radiating in posterior to anterior direction. A typical headache episode was characterized with severe intensity that often lasted several hours. There were no associated symptoms such as nausea, emesis, or photophobia, or aura. Neurology was consulted for evaluation and management of these headaches. The diagnosis of occipital neuralgia was made along with recommendations for bilateral occipital nerve blocks and the addition of gabapentin to his regimen. Bilateral occipital nerve blocks were performed under ultrasound guidance with 3 mL 0.25% bupivacaine and epinephrine. The patient reported relief of his headaches and had no complaints of lingering headaches upon hospital discharge or at his outpatient follow-up visit. Discussion/References: To be presented on poster. Funding: No funding or financial interests. A255 CONTINUOUS POSTOPERATIVE ANALGESIA VIA QUADRATUS LUMBORUM (QL) BLOCK - AN ALTERNATIVE TO TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK N. Yakovleva, M. Visoiu 1 Anesthesiology, Acute Interventional Perioperative Pain Service, University of Pittsburgh Medical 2 Center, Department of Anesthesiology, Acute Interventional Perioperative Pediatric Pain Service, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA Continuous administration of local anesthetic via TAPcatheter provides satisfactory postoperative analgesia for lower abdominal surgery (1,2). We report a case of successfully performed continuous quadratus lumborum block that provided effective postoperative analgesia in a child requiring colostomy closure. The patient is a 5 years old girl, 23 kg, scheduled for colostomy takedown. She had a colostomy after blunt rectal trauma. Continuous QL block was performed after completion of surgery, with the patient´s left side up. After cleaning the skin a high frequency probe connected to an S-nerve ultrasound machine was positioned with a transverse orientation, between iliac crest and costal margin and QL muscle was visualized (Figure 1). An 18G, 9cm Tuohy needle was oriented in plane, from anterior to posterior direction, the needle tip was positioned between the anterior border of QL muscle and its fascia. After negative aspiration, 10 ml of ropivacaine 0.5 % was injected .The needle held in place and a 20G multi-orifice catheter advanced between the QL muscle and its fascia, left at 13.5 cm at skin. A posterior spread of normal saline solution under QL muscle seen with real time Doppler imaging, confirming the catheter position. [Ultrasound image of QL muscle] The amount of intraoperative opioids was 3.7 mcg /kg of fentanyl, and 0.065 mg/kg of morphine. Ropivacaine 0.2% infusion started at 5 ml/hr, or 0.43mg/kg/hr. In 2 hours after the completion of the surgery, the patient was able to ambulate to the bathroom. She reported complete loss of sensation for touch and temperature across her left abdomen, under umbilicus, up to midline. She received morphine 0.96 mg/kg, on postoperative day (POD) 1, and 0.48 mg/kg, on POD 2. The minimum pain score was 0/10, the highest pain score was 4/10, with a mean pain score of 0.42/10 and a median pain score of 1/10. The catheter remained in place for 3 days and removed after administration of acetaminophen 12 mg/kg, by mouth. The patient was discharged on POD 4. To our knowledge, this is the first case reported of continuous QL block. QL muscle inserts into the lower border of the last rib and by four small tendons into the apices of the transverse processes of the upper four lumbar vertebrae. Between its fascia and the muscle are the twelfth thoracic, ilioinguinal and iliohypogastric nerves. The local anesthetic deposited under QL muscle can be transported into paravertebral space along tissue plane, but also along vascular, lymphatic and nervous system. Additional research is required to determine the relative indication of this continuous technique of local anesthetic infusion compared to TAP and paravertebral. 1. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Reg Anesth Pain Med 2012;37:193-209. 2. Visoiu M, Boretsky KR, Goyal G, Cladis FP et al. Postoperative analgesia via transversus abdominis plane (TAP) catheter for small weight children-our initial experience. Pediatr Anesth 2012;22:281-4. A signed parental consent was obtained. There is no funding for this research. The authors reported no conflicts of interest A256 INSERTION OF PERIPHERAL NERVE CATHETERS USING IN-PLANE NEEDLE INSERTION WITH LONG AXIS VIEWS OF THE NERVES M. Yared, W. Ali Sakr Esa, H. Elsharkawy Cleveland Clinic Foundation, Cleveland, OH, USA Continuous peripheral nerve catheters are used to provide prolonged post-operative analgesia. Having the catheter closer to the target nerve may potentially decrease the total volume of local anesthetic required. Challenges involved with catheter placement include losing visualization of the catheter tip as it is advanced. The ultrasound-guided catheter insertion approaches include: 1. Needle in-plane, nerve short-axis, 2. Needle out-of-plane, nerve short-axis, and 3. Needle in-plane, nerve long-axis. With the needle in-plane, nerve short-axis technique, it is easier to identify structures and to find the catheter tip relative to the nerve. However, since the needle is perpendicular to the nerve, when the catheter is threaded, it may go beyond the nerve. With the needle out-of-plane, nerve short-axis approach, the needle and nerve are parallel to each other which can potentially allow the catheter to stay closer to the nerve when threaded. However, the needle appears as a dot, which could represent the tip or the shaft, and thus compromise safety. The needle in-plane and nerve long-axis technique is more technically difficult and potentially more time consuming to perform because it requires precise alignment of the US beam with the needle and the nerve and a relatively straight nerve. However, the entire shaft and tip of the needle can be visualized. It also aligns the nerve, needle, and catheter parallel to each other which potentially allows for more control over the positioning of the catheter since there is better visualization of the catheter's advancement in relationship to the nerve. We performed four cases of peripheral nerve catheter placement using long-axis views of the nerves while maintaining the needle in-plane with the US. We performed this on the femoral, sciatic, popliteal, and supraclavicular plexus nerves. First, we identified the nerves in short axis then rotated the probe 90 degrees. With minor probe manipulation, we advanced the needle in-plane and then advanced the catheter under real time ultrasound guidance 5 cm beyond the tip of the needle. We injected local anesthetic which showed optimum position of the catheter tip in all cases. Although the in-plane, long axis approach has rarely been reported, we did not find this technique difficult to perform. We encountered some difficulty identifying the supraclavicular plexus nerves in their long axis views. We were successful in using this approach to place the nerve catheters and did not have any incidence of secondary catheter failure. Future studies are needed to evaluate whether aligning the catheter and the nerve parallel to each other would prevent migration of the catheter away from the nerve and decrease the incidence of secondary nerve catheter failure. [Femoral Nerve Long Axis View] [Supraclavicular Plexus Nerves in Long-Axis View] References: Ilfeld BM, MD, MS, Fredrickson MJ, MD, and Mariano ER, MD, MAS. Ultrasound-Guided Perineural Catheter Insertion: Three Approaches, but Little Illuminating Date. Reg Anesth Pain Med. 2010; 35(2): 123-126. Koscielniak-Nielsen ZJ, MD PhD FRCA, Rasmussen H, MD, and Hesselbjerg L, MD. Long-Axis Ultrasound Imaging of the Nerves and Advancement of Perineural Catheters Under Direct Vision: A Preliminary Report of Four Cases. Reg Anesth Pain Med. 2008; 33(5): 477-482. A257 PULMONARY EMBOLISM DURING DORSAL COLUMN STIMULATOR (DCS) TRIAL Vikas Kumar, M.D., Palak Bipin Turakhia, M.D., Manoj Subbarao Wunnava, M.D. Anesthesiology, Univ. of North Carolina Hospitals, Chapel Hill, NC, USA Background We present the case of an 85 year old female with spinal stenosis, previously responsive to injection therapy but with declining efficacy over time. The patient had also been trialed on various oral agents including gabapentin, hydrocodone/APAP and baclofen with minimal relief. She was deemed an appropriate candidate for a dorsal column stimulator. The patient´s medical history was significant for breast cancer that had been treated with a partial mastectomy and radiation therapy. She also had a history of deep venous thromboembolism and was anticoagulated with warfarin. After obtaining clearance from her hematologist-oncologist, the patient was discontinued from her warfarin therapy and underwent a percutaneous dorsal column stimulator trial. Two days into the trial, the patient developed a symptomatic pulmonary embolism (PE) with associated right heart strain and atrial fibrillation. She was admitted to an outside hospital for stabilization but was started on systemic anticoagulation with enoxaparin and warfarin prior to the date of her planned trial lead removal. We ultimately readmitted the patient, transitioned her anticoagulation to a heparin infusion and then pulled the trial dorsal column stimulator lead once the her coagulation profile had normalized. Specifically, we adhered to the guidelines for epidural catheters set forth by the American Society of Regional Anesthesia and Pain Medicine. This was our only reference since specific guidelines do not exist for neuromodulation therapies. Objective To research the incidence of PE/deep venous thrombosis (DVT) after dorsal column stimulator implantation in the literature and evaluate risk of recurrent PE/DVT after cessation of anticoagulation therapy. In addition, we hope to discuss any recommendations for discontinuation of anticoagulation and surveillance prior to cessation of anticoagulation in a high risk patient population. Methods Pubmed literature search Results/Discussion Venous thromboembolism during dorsal column stimulator trial or after permanent implantation must be an exceedingly rare complication, as there are no case reports in the literature describing such a complication. Recurrent venous thromboembolism after cessation of anticoagulation, however, is quite a common occurrence, with incidences as high as 50% in observational studies. It is common practice now to continue anticoagulation indefinitely in patients who are high risk for recurrence and low risk for bleeding complications. Prior to proceeding with discontinuation for any of our procedures, we must have a conversation with regards to risk stratification with both the patient and their hematologist/oncologist. References 1. Agnelli G, Becattini C. Treatment of DVT: how long is enough and how do you predict recurrence. J Thromb Thrombolysis. 2008 Feb;25(1):37-44. Epub 2007 Oct 1. 2. Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol. 2012 May;87 Suppl 1:S63-7. Epub 2012 Feb 24. 3. Horlocker TT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101. 4. Konstantinides S, Goldhaber SZ. Pulmonary embolism: risk assessment and management. Eur Heart J. 2012 Dec;33(24):3014-22. Epub 2012 Sep 7. Funding No grants or third-party research funding was utilized.