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Biomedical subjects

Brian M Ilfeld

Publications and source records attributed to Brian M Ilfeld.

At least 19 recordsLinked to original sources
PubMed2006

Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study.

BACKGROUND: A continuous interscalene nerve block (CISB) may be used to provide analgesia after shoulder arthroplasty. Therefore, inpatient stays may be shortened if CISB (1) provides adequate analgesia without intravenous opioids and (2) improves shoulder mobilization. This study investigated the relationship between ambulatory CISB and the time to reach three discharge criteria after shoulder arthroplasty. METHODS: Preoperatively, patients received a CISB. All patients received a perineural 0.2% ropivacaine infusion from surgery until 06:00 the following morning, at which time they were randomly assigned either to continue perineural ropivacaine or to switch to normal saline. The primary endpoint was the time from the end of surgery until three discharge criteria were attained (adequate analgesia, independence from intravenous analgesics, and tolerance to 50% of shoulder motion targets). Patients were discharged home as early as the afternoon after surgery with their CISB using a portable infusion pump. RESULTS: Patients receiving perineural ropivacaine (n = 16) attained all three discharge criteria in a median (10th-90th percentiles) of 21 (16-41) h, compared with 51 (37-90) h for those receiving perineural normal saline (n = 13, P < 0.001). Unlike patients receiving perineural ropivacaine, patients receiving perineural normal saline often required intravenous morphine, but still experienced a higher degree of pain and tolerated less external rotation. CONCLUSIONS: An ambulatory CISB considerably decreases the time until readiness for discharge after shoulder arthroplasty, primarily by providing potent analgesia that permits greater passive shoulder movement and the avoidance of intravenous opioids. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with earlier discharge.

Aged↗
PubMed2006

Total knee arthroplasty as an overnight-stay procedure using continuous femoral nerve blocks at home: a prospective feasibility study.

The average duration of hospitalization after total knee arthroplasty (TKA) in the United States is 4-5 days. In this two-phase study we investigated the feasibility of converting TKA into an overnight-stay procedure using a continuous femoral nerve block provided at home through postoperative day 4. Nine of 10 patients met discharge criteria and were discharged home the day after surgery. Pain was well controlled, opioid requirements and sleep disturbances were minimal, and patient satisfaction was high. Additional research is required to replicate these results in a controlled trial, define the appropriate subset of patients, and assess the incidence of complications associated with this practice before its mainstream use.

Adolescent↗
PubMed2005

Clonidine added to a continuous interscalene ropivacaine perineural infusion to improve postoperative analgesia: a randomized, double-blind, controlled study.

Although clonidine has been shown to increase the duration of local anesthetic action and prolong postoperative analgesia when included in single-injection nerve blocks, the only controlled investigation of the efficacy of this practice to improve analgesia for continuous perineural local anesthetic infusion failed to discern any clinically relevant benefits. For this study, we used a larger dose of clonidine in an attempt to improve analgesia. Patients (n = 20) undergoing moderately painful orthopedic surgery of the shoulder received an interscalene brachial plexus block (40 mL of mepivacaine 1.5%, epinephrine 2.5 microg/mL, and clonidine 50 microg) and a perineural catheter before surgery. After surgery, ropivacaine 0.2% or ropivacaine 0.2% plus clonidine 2 microg/mL was delivered via the catheter for 3 days (basal rate, 5 mL/h; patient-controlled bolus, 5 mL; lockout, 1 h). Investigators and patients were blind to random group assignment. The primary outcome variable was designated as the most intense pain during the day after surgery. Secondary end-points included additional pain scores, patient-controlled bolus doses, oral analgesic use, sleep quality, and catheter- or infusion-related complications. There were no statistically significant differences between groups for any of the variables investigated. We conclude that adding clonidine 2 microg/mL to a ropivacaine interscalene perineural infusion does not decrease breakthrough pain intensity the day after surgery. For the additional end-points, our negative findings are only suggestive of a lack of effect and require further study for verification.

Adrenergic alpha-Agonists↗
PubMed2005

Continuous peripheral nerve blocks at home: a review.

Postoperative analgesia is generally limited to 12-16 h or less after single-injection regional nerve blocks. Postoperative analgesia may be provided with a local anesthetic infusion via a perineural catheter after initial regional block resolution. This technique may now be used in the outpatient setting with the relatively recent introduction of reliable, portable infusion pumps. In this review article, we summarize the available published data related to this new analgesic technique and highlight important issues related specifically to perineural infusion provided in patients' own homes. Topics include infusion benefits and risks, indications and patient selection criteria, catheter, infusion pump, dosing regimen, and infusate selection, and issues related specifically to home-care.

Anesthetics, Local↗
PubMed2005

Total shoulder arthroplasty as an outpatient procedure using ambulatory perineural local anesthetic infusion: a pilot feasibility study.

We investigated the feasibility of converting total shoulder arthroplasty (TSA) into an outpatient procedure using ambulatory interscalene perineural ropivacaine infusion. Of the patients of the first phase (n = 8) who were required to remain hospitalized for at least 1 postoperative night, 5 met discharge criteria in the recovery room. Of the subsequent patients of the second phase (n = 6), all met discharge criteria in the recovery room after surgery, and 5 were discharged directly home. For all patients, postoperative pain was well controlled, oral opioid requirements and sleep disturbances were minimal, range-of-motion consistently reached or exceeded the surgeon's expectations, and patient satisfaction was high. These results suggest that TSA may be performed on an outpatient basis using perineural local anesthetic infusion. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with this practice before its mainstream use.

Adult↗
PubMed2004

Infraclavicular perineural local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia.

BACKGROUND: In this randomized, double-blind study, the authors investigated the efficacy of continuous and patient-controlled ropivacaine infusions via an infraclavicular perineural catheter in ambulatory patients undergoing moderately painful orthopedic surgery at or distal to the elbow. METHODS: Preoperatively, patients (n = 30) received an infraclavicular perineural catheter and nerve block. Postoperatively, patients were discharged home with both oral analgesics and a portable infusion pump delivering 0.2% ropivacaine (500-ml reservoir) in one of three dosing regimens: the basal group (12 ml/h basal, 0.05-ml patient-controlled bolus dose), the basal-bolus group (8 ml/h basal, 4 ml bolus), or the bolus group (0.3 ml/h basal, 9.9 ml bolus). Investigators and patients were blinded to random group assignment. RESULTS: The basal group (n = 10) required more oral analgesics than the basal-bolus group (P = 0.002) and had a shorter median infusion duration than the other two groups (P < 0.001 for both). The bolus group had the longest median infusion duration (P < 0.001 for both) but experienced an increase in breakthrough pain incidence (P = 0.004) and intensity (P = 0.04 vs. basal-bolus group) as well as sleep disturbances (P < 0.001 for both) compared with the other groups. Overall satisfaction was greatest in the basal-bolus group (9.7 +/- 0.5 vs. 7.9 +/- 1.7 and 8.1 +/- 1.5; P < 0.05 for both). CONCLUSIONS: After moderately painful orthopedic surgery at or distal to the elbow, 0.2% ropivacaine delivered as a continuous infusion combined with patient-controlled bolus doses via an infraclavicular perineural catheter optimizes analgesia while minimizing oral analgesic use compared with basal- or bolus-only dosing regimens.

Amides↗
PubMed2004

Popliteal sciatic perineural local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia.

BACKGROUND: This randomized, double-blind study investigated the efficacy of continuous and patient-controlled ropivacaine infusion via a popliteal sciatic perineural catheter in ambulatory patients undergoing moderately painful orthopedic surgery of the foot or ankle. METHODS: Preoperatively, patients (n = 30) received a posterior popliteal sciatic perineural catheter and nerve block. Postoperatively, patients were discharged home with a portable infusion pump delivering 0.2% ropivacaine (500 ml) in one of three dosing regimens: the basal group (12-ml/h basal rate, 0.05-ml patient-controlled bolus dose), the basal-bolus group (8-ml/h basal rate, 4-ml bolus dose), or the bolus group (0.3-ml/h basal rate, 9.9-ml bolus dose). RESULTS: The bolus group experienced an increase in baseline pain, breakthrough pain incidence and intensity, and sleep disturbances compared with the other two groups (P < 0.05 for all comparisons). Compared with the basal-bolus group, the basal group experienced an increase in these outcome measures only after local anesthetic reservoir exhaustion, which occurred earlier than in the other two groups (P < 0.05 for all comparisons). Satisfaction scores did not differ among the three groups. CONCLUSIONS: This study demonstrates that when providing analgesia with 0.2% ropivacaine via a popliteal sciatic perineural catheter after moderately painful surgery of the foot or ankle, a continuous infusion is required to optimize infusion benefits. Furthermore, adding patient-controlled bolus doses allows for a lower continuous basal rate and decreased local anesthetic consumption and thereby increases the duration of infusion benefits when in an ambulatory environment with a limited local anesthetic reservoir.

Adult↗
PubMed2003

Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

UNLABELLED: In this study, we investigated the efficacy of patient-controlled regional analgesia for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Preoperatively, patients (n = 20) received an interscalene nerve block and perineural catheter. Postoperatively, patients were discharged home with both oral opioids and a portable infusion pump delivering either 0.2% ropivacaine or 0.9% saline, determined randomly in a double-blinded manner. Daily end points included pain scores, opioid use and side effects, sleep quality, and technique complications. Ropivacaine (n = 10) infusion significantly reduced pain compared with saline (n = 10) infusion. The average pain at rest (scale: 0-10) on postoperative day 1 (median, 25th-75th percentiles) was 4.8 (4.0-5.0) for the saline group, versus 0.0 (0.0-2.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were also significantly decreased in the ropivacaine group. On postoperative day 1, median tablet consumption was 8.0 (6.5-9.5) and 0.5 (0.0-1.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were nearly threefold greater on the first postoperative night for patients receiving saline (P = 0.013). We conclude that after moderately painful orthopedic surgery of the shoulder, ropivacaine infusion using a portable infusion pump and an interscalene perineural catheter at home decreased pain, opioid use and related side effects, and sleep disturbances. IMPLICATIONS: This randomized, double-blinded, placebo-controlled study demonstrated that ropivacaine, infused with a portable infusion pump via an interscalene perineural catheter for 3 days at home, significantly decreased postoperative pain after orthopedic surgery of the shoulder. In addition to providing potent analgesia and increasing patient satisfaction, perineural infusion decreased opioid requirements and their associated side effects.

Aged↗
PubMed2003

Continuous infraclavicular perineural infusion with clonidine and ropivacaine compared with ropivacaine alone: a randomized, double-blinded, controlled study.

Although clonidine has been shown to increase the duration of local anesthetic action and prolong postoperative analgesia when included in single-injection nerve blocks, a controlled investigation of the efficacy of this practice to improve analgesia for continuous perineural local anesthetic infusion has not been reported. In this study, ambulatory patients (n = 34) undergoing moderately painful upper extremity orthopedic surgery received an infraclavicular brachial plexus block (mepivacaine 1.5%, epinephrine 2.5 micro g/mL, and bicarbonate 0.1 mEq/mL) and a perineural catheter before surgery. After surgery, patients were discharged home with a portable infusion pump delivering either ropivacaine 0.2% or ropivacaine 0.2% plus clonidine 1 micro g/mL via the catheter for 3 days (basal, 8 mL/h; patient-controlled bolus, 2 mL every 20 min). Investigators and patients were blinded to random group assignment. Daily end-points included pain scores, patient-controlled bolus doses, oral analgesic use, sleep quality, and symptoms of catheter- or infusion-related complications. Adding clonidine to ropivacaine resulted in a statistically significant decrease in the number of self-administered 2-mL bolus doses on postoperative Days 0 and 1 (P < 0.02), but this decreased actual local anesthetic consumption by an average of only 2-7 mL/d (P < 0.02). There were no statistically significant differences between the two groups for any of the other variables investigated, including sleep quality or oral analgesic requirements. We conclude that adding 1 micro g/mL of clonidine to a ropivacaine infraclavicular perineural infusion does not provide clinically relevant improvements in analgesia, sleep quality, or oral analgesic requirements for ambulatory patients having moderately painful upper extremity surgery.

Adrenergic alpha-Agonists↗
PubMed2002

The delivery rate accuracy of portable infusion pumps used for continuous regional analgesia.

UNLABELLED: Portable pumps used for local anesthetic infusion during continuous regional analgesia are gaining acceptance. These pumps are often used for ambulatory patients who are medically unsupervised throughout most of the infusion. However, the performance of these pumps, which infuse potentially toxic medication, has not been independently investigated. We investigated the flow rate accuracy, consistency, and profiles of various portable pumps often used for local anesthetic infusion during continuous regional analgesia. By using a computer/scale combination within a laboratory to record infusion rates, 6 pumps were tested with their flow regulators at expected (30 degrees-32 degrees C) and increased (34 degrees-36 degrees C) temperatures. Infusion rate accuracy differed significantly among the pumps, exhibiting flow rates within +/-15% of their expected rate for 18%-100% of their infusion duration. An increase in temperature also affected pumps to differing degrees, with infusion rates increasing from 0% to 25% for each model tested. These results suggest that factors such as flow rate accuracy and consistency, infusion profile, and temperature sensitivity should be considered when choosing and using a portable infusion pump for local anesthetic administration. IMPLICATIONS: Portable pumps often used for local anesthetic infusion during continuous regional analgesia exhibit varying degrees of delivery rate accuracy and consistency. Furthermore, increases in temperature result in an increased infusion rate for various pumps investigated. These factors should be taken into consideration when choosing and using a portable infusion pump.

Anesthesia, Conduction↗
PubMed2002

Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

BACKGROUND: This randomized, double-blinded, placebo-controlled study investigated the efficacy of patient-controlled regional analgesia using an infraclavicular brachial plexus perineural catheter and a portable infusion pump for outpatients undergoing moderately painful, upper extremity orthopedic surgery. METHODS: Preoperatively, patients (n = 30) received an infraclavicular nerve block and perineural catheter. Postoperatively, patients were discharged home with oral narcotics and a portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days. Investigators and patients were blinded to random group assignment. Daily end points included pain scores at rest and with limb movement, narcotic use and side effects, sleep quality, patient satisfaction, and symptoms of catheter- or local anesthetic-related complications. RESULTS: Ropivacaine (n = 15) infusion significantly reduced pain compared with saline (n = 15) infusion (P < 0.001). For example, the average pain with movement (scale, 0-10) on postoperative day 1 was 6.1 +/- 2.3 for the saline group versus 2.5 +/- 1.6 for the ropivacaine group (P < 0.001). Oral narcotic use and related side effects were significantly decreased in the ropivacaine group. For example, on postoperative day 1, mean tablet consumption was 5.5 +/- 2.4 and 1.7 +/- 1.6 for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were 10-fold greater for saline administration than for ropivacaine infusion (P < 0.001). Overall satisfaction was significantly greater in the ropivacaine group. No catheter- or local anesthetic-related complications occurred. CONCLUSION: After moderately painful orthopedic surgery of the upper extremity, ropivacaine infusion using a portable, mechanical pump and an infraclavicular brachial plexus perineural catheter at home decreased pain, sleep disturbances, narcotic use and related side effects, and improved overall satisfaction.

Adult↗
PubMed2002

Continuous popliteal sciatic nerve block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.

BACKGROUND: This randomized, double-blinded, placebo-controlled study investigated the efficacy of patient-controlled regional analgesia using a sciatic perineural catheter in the popliteal fossa and a portable infusion pump for outpatients having moderately painful, lower extremity orthopedic surgery. METHODS: Preoperatively, patients (n = 30) received a sciatic nerve block and perineural catheter in the popliteal fossa. Postoperatively, patients were discharged with both oral opioids and a portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days. Investigators and patients were blinded to random group assignment. Daily end-points included pain scores, opioid use and side effects, sleep quality, and symptoms of catheter- or local anesthetic-related complications. RESULTS: Ropivacaine (n = 15) infusion significantly reduced pain compared with saline (n = 15) infusion ( < 0.001). For example, the average pain at rest (scale: 0-10) on postoperative day 1 (median, 25th -75th percentile) was 4.0 (3.5-5.5) for the saline group, versus 0.0 (0.0-0.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were significantly decreased in the ropivacaine group. For example, on postoperative day 1, median tablet consumption was 8.0 (5.0-10.0) and 0.0 (0.0-0.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were more than 10-fold greater for saline administration than for ropivacaine infusion (P < 0.001). Overall satisfaction was significantly greater in the ropivacaine group. Other than two inadvertent catheter dislodgements, no catheter- or local anesthetic-related complications occurred. CONCLUSIONS: After moderately painful orthopedic surgery of the lower extremity, ropivacaine infusion using a portable mechanical pump and a popliteal sciatic perineural catheter at home decreased pain, opioid use and related side effects, sleep disturbances, and improved overall satisfaction.

Adult↗
PubMedDate not supplied

Interscalene perineural ropivacaine infusion:a comparison of two dosing regimens for postoperative analgesia.

UNLABELLED: BACKGROUND AND OBJECTIVS: A continuous interscalene nerve block with a perineural infusion of ropivacaine 0.2% at 8 mL/h has been shown to provide potent analgesia following moderately painful shoulder surgery. However, this high basal rate limits infusion duration for ambulatory patients who must carry the local anesthetic reservoir. We undertook this investigation to determine if the basal rate of an interscalene perineural ropivacaine infusion could be decreased by 50% with a concurrent 200% increase in patient-controlled bolus dose without compromising infusion benefits in ambulatory patients undergoing moderately painful orthopedic shoulder surgery. METHODS: Preoperatively, patients (n = 24) received an interscalene perineural catheter and nerve block. Intraoperatively, patients received a standardized general anesthetic. Postoperatively, patients were discharged home with a portable infusion pump delivering ropivacaine 0.2% (500 mL reservoir) with a basal rate of 8 mL/h and a 2 mL patient-controlled bolus available each hour ("8/2" group, n = 12) or a 4 mL/h basal rate and 6 mL bolus dose ("4/6" group, n = 12), delivered in a randomized, double-blinded manner. RESULTS: Patients in the 4/6 group had higher baseline pain scores only on postoperative day (POD) 2 (P =.011). However, these patients also experienced an increase in breakthrough pain incidence (5.8 boluses/d v 3.2, P =.035) and intensity ("worst" pain = 8/10 v 4/10, P <.05), sleep disturbances (2.0 v 0.0, P <.001), and a decrease in analgesia satisfaction (8 v 10, P =.003). Patients in the 8/2 group exhausted their local anesthetic reservoirs after a median of 61 hours, while the 4/6 group had a median of 131 mL remaining at infusion discontinuation after a median of 75 hours (P <.001). CONCLUSIONS: Following moderately painful ambulatory shoulder surgery, decreasing an interscalene perineural ropivacaine 0.2% basal rate from 8 to 4 mL/h provides similar baseline analgesia and lengthens infusion duration, but compromises other infusion benefits.

Aged↗
PubMedDate not supplied

Development of a standardized peripheral nerve block procedure note form.

OBJECTIVES: Despite the tremendous growth of peripheral nerve blocks, no standard format exists to document their performance. Our objective was to create a peripheral nerve block form based on key elements of literature evidence and on our own group consensus. RESULTS: We describe the process and results of our multi-institutional effort to construct a standardized peripheral nerve block procedure form. CONCLUSION: A form was developed to help meet the medical, legal, and billing requirements of documentation consistent with the performance of peripheral nerve block.

Humans↗