LETTERS TO THE EDITOR
Epidural Removal After Perioperative Myocardial Infarction and Coronary Stent Placement Accepted for Publication: January 15, 2014. To the Editor: e report the case of a 77-year-old, 72.3-kg, white man with degenerative joint disease, anemia, thalassemia minor, and tobacco abuse but otherwise negative history and preoperative evaluation, who experienced an ST-segment elevation myocardial infarction (STEMI) after total hip arthroplasty with an indwelling epidural catheter. Written consent and an institutional review board exemption were obtained to report this case. On skin closure, ST-segment elevations developed and ventricular fibrillation soon followed. Advanced cardiovascular life support protocols restored sinus rhythm, and systemic anticoagulation was initiated (intravenous unfractionated heparin, rectal clopidogrel, and aspirin). On cardiac catheterization, multivessel disease was diagnosed and a bare metal stent was placed. The patient was transferred to the intensive care unit, intubated, and sedated. Based on platelet aggregometry that revealed 0% inhibition of platelets and normal coagulation studies, the epidural catheter was removed. The patient was extubated on postoperative day 1 and later discharged to a skilled nursing facility free of neurologic deficits. Neuraxial catheter removal in conjunction with thienopyridines carries the risk of spinal hematoma formation; however, dual antiplatelet therapy is a central component in the management of STEMI patients.1 Thienopyridine effects are time and dose dependent, with loading doses accelerating attainment of steady state. Platelet function testing may help determine the risk of thrombotic or hemorrhagic events while using antiplatelet therapy. The VerifyNow System (Accumetrics, Inc, San Diego, California) was used to investigate the effects of clopidogrel on our patient. Although the VerifyNow system lacks the sensitivity of “gold standard” conventional platelet aggregometry, it has been shown to provide significant correlation to platelet aggregometry in patients undergoing dual antiplatelet therapy.2 Given the emergent nature of the
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clinical dilemma presented, rapid point-ofcare information (VerifyNow) assisted in the clinical decision for neuraxial catheter removal. Three previous case reports have described similar situations, except medications were held until laboratory data normalized, resulting in 1 indwelling epidural catheter for 4 weeks.3–5 This case differs because it demonstrates that early assessment may permit epidural catheter removal without cessation of antiplatelet therapy. Christopher W. Hackney, MD Sylvia H. Wilson, MD James H. Abernathy, MD Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Matthew D. McEvoy, MD Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
The authors declare no conflict of interest. REFERENCES 1. Adesanya AO, de Lemos JA, Greilich NB, Whitten CW. Management of perioperative myocardial infarction in noncardiac surgical patients. Chest. 2006;130:584–596. 2. Paniccia R, Antonucci E, Gori AM, et al. Different methodologies for evaluating the effect of clopidogrel on platelet function in high-risk coronary artery disease patients. J Thromb Haemost. 2007;5:1839–1847. 3. Bergmann L, Kienbaum P, Görlinger K, Peters J. Uneventful removal of an epidural catheter guided by impedance aggregometry in a patient with recent coronary stenting and treated with clopidogrel and acetylsalicylic acid. Reg Anesth Pain Med. 2007;32:354–357. 4. Burad J, Kausalya R, Ismaili M, Tawafic Q, Date R. Safe removal of epidural catheter—a dilemma, in patients who are started on dual anti platelet therapy postoperatively for acute coronary syndrome—a case report. Middle East J Anesthesiol. 2012;21:905–908. 5. Glenn E, Mehl J, Rosinia FA, Liu H. Safe removal of an epidural catheter 72 hours after clopidogrel and aspirin administrations guided by platelet function analysis and thromboelastography. J Anaesthesiol Clin Pharmacol. 2013;1:99–101.
Fluoroscopically Guided Epidural Catheter Placement in a Patient With Osteoporosis Pseudoglioma Undergoing Bilateral Femoral Osteotomies Accepted for Publication: January 8, 2014. To the Editor: e report on the perioperative care of a 16-year-old girl with a medical history of osteoporosis pseudoglioma (OPPG) who presented for bilateral femoral osteotomy revisions. Her surgical history was significant for multiple orthopedic operations on both lower extremities complicated by extended hospital time because of inadequate analgesia and development of chronic postoperative pain with the need for chronic oral opioid therapy. We report successful perioperative pain management of this complex patient using a fluoroscopically guided low thoracic epidural catheter. The patient’s legal guardian has given permission to publish this report. Osteoporosis pseudoglioma is a rare autosomal recessive syndrome that presents with severe juvenile osteoporosis and congenital blindness caused by mutations in the lipoprotein receptor–related protein 5 (LRP5) gene.1,2 Osteoporosis pseudoglioma usually presents with recurrent long-bone fractures, reductions in bone mineral density, compression fractures, and kyphoscoliosis.3 Like many other patients with this syndrome, our patient had severe symptomatic osteoporosis with an extensive history of repeated long-bone fractures that required multiple surgical interventions. Postoperative acute pain management was suboptimal after the patient’s previous orthopedic surgeries. Pain management with intravenous opioid was fraught with significant side effects, including somnolence, nausea, and respiratory depression, resulting in the withholding of analgesics and delays in postsurgical progress. Neuraxial analgesia had not been attempted because of concern for technical difficulty and increased risk of needle-related trauma given severe scoliosis and osteopenia. After induction of general endotracheal anesthesia and placement of vascular access, the patient was turned to the left lateral decubitus position. Fluoroscopy was used to confirm low thoracic position,
W
Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
and a meticulous biplanar technique was used to guide an 18-gauge Tuohy needle into the T12/L1 interspace with minimal bony contact. Loss of resistance to saline was met at a depth of 4.5 cm, and a 20-gauge epidural catheter was threaded easily 4 cm into the epidu space. An 18-gauge 2-inch Crawford needle was used to tunnel the catheter subcutaneously. An anteroposterior and lateral epidurogram was performed with 2 mL of iohexol (Omnipaque 300; GE Healthcare, Cork, Ireland). The catheter position was confirmed at T12 with adequate midline vertical spread in a pattern consistent with posterior and anterior epidural spread (Fig. 1). The patient was returned to the supine position, and the epidural catheter was periodically bolused with 0.25% bupivacaine with 1:200,000 epinephrine intraoperatively to maintain analgesia. The operative procedure was uneventful. The patient was extubated and later discharged to the ward. Postoperatively, the patient was placed on patient-controlled epidural analgesia with an epidural infusion containing 0.1% ropivacaine, 2 μg/mL fentanyl, and 0.5 μg/mL clonidine. The basal rate was set at 10 mL/h with 2 mL every 30 minutes demand. Scheduled oral acetaminophen 650 mg every 6 hours was used as a pain adjunct. On postoperative day (POD) 2, the basal rate was increased to 12 mL/h, and analgesia was reported to be excellent. The epidural catheter was removed on POD 4 after successful transition to oral hydrocodone/ acetaminophen 7.5/500 every 4 hours. She was discharged on POD 4. Both patient and family reported superior analgesia and reduced hospital stay compared with earlier admissions for similar orthopedic operations. Successful placement of an epidural catheter can be a challenging task in children with OPPG given the relative fragility of bony structures and high incidence of preexisting vertebral column abnormalities.
However, we suggest that an epidural catheter placed under meticulous fluoroscopic guidance to minimize damage to surrounding tissue may be an appropriate option for children with OPPG undergoing lowerextremity surgery. Indeed, epidural analgesia has been shown to provide postoperative analgesia superior to intravenous patientcontrolled analgesia4 and may also reduce hospital length of stay.5 Inadequately managed acute pain may possibly lead to chronic pain states, and this must be taken into consideration when planning anesthetics for patients with chronic painful diseases such as OPPG. Imaging modalities such as ultrasound and fluoroscopy continue to increase the safety of acute pain management techniques, and the option of regional anesthesia should be considered in all eligible patients to reduce the costs of inadequately treated perioperative pain.
Humphrey Lam, MD Aaron Broman, MD Andrew Franklin, MD Department of Anesthesiology Division of Pediatric Anesthesiology Vanderbilt University School of Medicine and Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, TN
The authors declare no conflict of interest. REFERENCES 1. Ai M, Heeger S, Bartels CF, Schelling DK. Clinical and molecular findings in osteoporosis-pseudoglioma syndrome. Am J Hum Genet. 2005;77:741–753. 2. Gong Y, Vikkula M, Boon L, et al. Osteoporosis-pseudoglioma syndrome, a disorder affecting skeletal strength and vision, is assigned to chromosome region 11q12–13. Am J Hum Genet. 1996;59:146–151. 3. Teebi AS, Al-Awadi SA, Marafie MJ, Bushnao RA, Satyanath S. Osteoporosis-pseudoglioma syndrome with congenital heart disease: a new association. J Med Genet. 1988;25:32–36. 4. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids. Anesthesiology. 2005;103:1079–1088.
FIGURE 1. Anteroposterior epidurogram.
5. Wilson GA, Brown JL, Crabbe DG, Hinton W, McHugh PJ, Stringer MD. Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? Paediatr Anaesth. 2001;11:65–70.
© 2014 American Society of Regional Anesthesia and Pain Medicine
Letters to the Editor
Defining Adductor Canal Block Accepted for Publication: December 4, 2013. To the Editor: e read with great interest the very thorough and well-executed article by Jæger et al concerning the comparison of the adductor canal block (ACB) versus the femoral nerve block for analgesia after total knee arthroplasty.1 However, we believe that some essential anatomical matters need to be addressed and clarified. The technique of the so-called ACB as described by the authors in the present and several previous articles consistently involved needle insertion halfway between the base of the patella and the anterior superior iliac spine (ASIS) under ultrasound to obtain a cross-sectional view of the femoral vessels and the saphenous nerve.1–4 Using an in-plane needle approach, a catheter was inserted via the needle, with the needle tip just lateral to the saphenous nerve lying lateral to the femoral artery, and 30 mL of ropivacaine 0.5% was injected via the catheter while visualizing sonographic expansion of the presumed adductor canal (AC). However, it is an anatomical matter of fact that the needle insertion point defined above is within the femoral triangle proximal to the AC. The AC extends from the apex of the femoral triangle to the adductor hiatus—and the apex of the femoral triangle is defined by the crossing of the medial margin of the adductor longus muscle and the medial margin of the sartorius muscle. The AC is a musculo-aponeurotic tunnel. It is roofed from the apex of the femoral triangle to the adductor hiatus by the vastoadductor membrane (VAM), which is a strong aponeurosis (also known as the anteromedial intermuscular septum or the subsartorial fascia) between the adductor longus and magnus muscles and the vastus medialis muscle. The sartorius muscle extends from the ASIS to the proximal medial surface of the tibia, and it runs anterior to the VAM. The AC is also known as the subsartorial canal, which might contribute to the confusion about the extent of the AC—considering that the sartorius muscle is the longest muscle in the body and much longer than the AC. The AC always contains the femoral vessels, the saphenous nerve, and the nerve to the vastus medialis muscle. The obturator nerve does often (but not always) enter the distal part of the AC and follows the femoral artery through the hiatus of the adductor magnus tendon to the popliteal
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Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Epidural Removal After Perioperative Myocardial Infarction and Coronary Stent Placement Accepted for Publication: January 15, 2014. To the Editor: e report the case of a 77-year-old, 72.3-kg, white man with degenerative joint disease, anemia, thalassemia minor, and tobacco abuse but otherwise negative history and preoperative evaluation, who experienced an ST-segment elevation myocardial infarction (STEMI) after total hip arthroplasty with an indwelling epidural catheter. Written consent and an institutional review board exemption were obtained to report this case. On skin closure, ST-segment elevations developed and ventricular fibrillation soon followed. Advanced cardiovascular life support protocols restored sinus rhythm, and systemic anticoagulation was initiated (intravenous unfractionated heparin, rectal clopidogrel, and aspirin). On cardiac catheterization, multivessel disease was diagnosed and a bare metal stent was placed. The patient was transferred to the intensive care unit, intubated, and sedated. Based on platelet aggregometry that revealed 0% inhibition of platelets and normal coagulation studies, the epidural catheter was removed. The patient was extubated on postoperative day 1 and later discharged to a skilled nursing facility free of neurologic deficits. Neuraxial catheter removal in conjunction with thienopyridines carries the risk of spinal hematoma formation; however, dual antiplatelet therapy is a central component in the management of STEMI patients.1 Thienopyridine effects are time and dose dependent, with loading doses accelerating attainment of steady state. Platelet function testing may help determine the risk of thrombotic or hemorrhagic events while using antiplatelet therapy. The VerifyNow System (Accumetrics, Inc, San Diego, California) was used to investigate the effects of clopidogrel on our patient. Although the VerifyNow system lacks the sensitivity of “gold standard” conventional platelet aggregometry, it has been shown to provide significant correlation to platelet aggregometry in patients undergoing dual antiplatelet therapy.2 Given the emergent nature of the
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clinical dilemma presented, rapid point-ofcare information (VerifyNow) assisted in the clinical decision for neuraxial catheter removal. Three previous case reports have described similar situations, except medications were held until laboratory data normalized, resulting in 1 indwelling epidural catheter for 4 weeks.3–5 This case differs because it demonstrates that early assessment may permit epidural catheter removal without cessation of antiplatelet therapy. Christopher W. Hackney, MD Sylvia H. Wilson, MD James H. Abernathy, MD Department of Anesthesia and Perioperative Medicine Medical University of South Carolina Charleston, SC
Matthew D. McEvoy, MD Department of Anesthesiology Vanderbilt University Medical Center Nashville, TN
The authors declare no conflict of interest. REFERENCES 1. Adesanya AO, de Lemos JA, Greilich NB, Whitten CW. Management of perioperative myocardial infarction in noncardiac surgical patients. Chest. 2006;130:584–596. 2. Paniccia R, Antonucci E, Gori AM, et al. Different methodologies for evaluating the effect of clopidogrel on platelet function in high-risk coronary artery disease patients. J Thromb Haemost. 2007;5:1839–1847. 3. Bergmann L, Kienbaum P, Görlinger K, Peters J. Uneventful removal of an epidural catheter guided by impedance aggregometry in a patient with recent coronary stenting and treated with clopidogrel and acetylsalicylic acid. Reg Anesth Pain Med. 2007;32:354–357. 4. Burad J, Kausalya R, Ismaili M, Tawafic Q, Date R. Safe removal of epidural catheter—a dilemma, in patients who are started on dual anti platelet therapy postoperatively for acute coronary syndrome—a case report. Middle East J Anesthesiol. 2012;21:905–908. 5. Glenn E, Mehl J, Rosinia FA, Liu H. Safe removal of an epidural catheter 72 hours after clopidogrel and aspirin administrations guided by platelet function analysis and thromboelastography. J Anaesthesiol Clin Pharmacol. 2013;1:99–101.
Fluoroscopically Guided Epidural Catheter Placement in a Patient With Osteoporosis Pseudoglioma Undergoing Bilateral Femoral Osteotomies Accepted for Publication: January 8, 2014. To the Editor: e report on the perioperative care of a 16-year-old girl with a medical history of osteoporosis pseudoglioma (OPPG) who presented for bilateral femoral osteotomy revisions. Her surgical history was significant for multiple orthopedic operations on both lower extremities complicated by extended hospital time because of inadequate analgesia and development of chronic postoperative pain with the need for chronic oral opioid therapy. We report successful perioperative pain management of this complex patient using a fluoroscopically guided low thoracic epidural catheter. The patient’s legal guardian has given permission to publish this report. Osteoporosis pseudoglioma is a rare autosomal recessive syndrome that presents with severe juvenile osteoporosis and congenital blindness caused by mutations in the lipoprotein receptor–related protein 5 (LRP5) gene.1,2 Osteoporosis pseudoglioma usually presents with recurrent long-bone fractures, reductions in bone mineral density, compression fractures, and kyphoscoliosis.3 Like many other patients with this syndrome, our patient had severe symptomatic osteoporosis with an extensive history of repeated long-bone fractures that required multiple surgical interventions. Postoperative acute pain management was suboptimal after the patient’s previous orthopedic surgeries. Pain management with intravenous opioid was fraught with significant side effects, including somnolence, nausea, and respiratory depression, resulting in the withholding of analgesics and delays in postsurgical progress. Neuraxial analgesia had not been attempted because of concern for technical difficulty and increased risk of needle-related trauma given severe scoliosis and osteopenia. After induction of general endotracheal anesthesia and placement of vascular access, the patient was turned to the left lateral decubitus position. Fluoroscopy was used to confirm low thoracic position,
W
Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 39, Number 3, May-June 2014
and a meticulous biplanar technique was used to guide an 18-gauge Tuohy needle into the T12/L1 interspace with minimal bony contact. Loss of resistance to saline was met at a depth of 4.5 cm, and a 20-gauge epidural catheter was threaded easily 4 cm into the epidu space. An 18-gauge 2-inch Crawford needle was used to tunnel the catheter subcutaneously. An anteroposterior and lateral epidurogram was performed with 2 mL of iohexol (Omnipaque 300; GE Healthcare, Cork, Ireland). The catheter position was confirmed at T12 with adequate midline vertical spread in a pattern consistent with posterior and anterior epidural spread (Fig. 1). The patient was returned to the supine position, and the epidural catheter was periodically bolused with 0.25% bupivacaine with 1:200,000 epinephrine intraoperatively to maintain analgesia. The operative procedure was uneventful. The patient was extubated and later discharged to the ward. Postoperatively, the patient was placed on patient-controlled epidural analgesia with an epidural infusion containing 0.1% ropivacaine, 2 μg/mL fentanyl, and 0.5 μg/mL clonidine. The basal rate was set at 10 mL/h with 2 mL every 30 minutes demand. Scheduled oral acetaminophen 650 mg every 6 hours was used as a pain adjunct. On postoperative day (POD) 2, the basal rate was increased to 12 mL/h, and analgesia was reported to be excellent. The epidural catheter was removed on POD 4 after successful transition to oral hydrocodone/ acetaminophen 7.5/500 every 4 hours. She was discharged on POD 4. Both patient and family reported superior analgesia and reduced hospital stay compared with earlier admissions for similar orthopedic operations. Successful placement of an epidural catheter can be a challenging task in children with OPPG given the relative fragility of bony structures and high incidence of preexisting vertebral column abnormalities.
However, we suggest that an epidural catheter placed under meticulous fluoroscopic guidance to minimize damage to surrounding tissue may be an appropriate option for children with OPPG undergoing lowerextremity surgery. Indeed, epidural analgesia has been shown to provide postoperative analgesia superior to intravenous patientcontrolled analgesia4 and may also reduce hospital length of stay.5 Inadequately managed acute pain may possibly lead to chronic pain states, and this must be taken into consideration when planning anesthetics for patients with chronic painful diseases such as OPPG. Imaging modalities such as ultrasound and fluoroscopy continue to increase the safety of acute pain management techniques, and the option of regional anesthesia should be considered in all eligible patients to reduce the costs of inadequately treated perioperative pain.
Humphrey Lam, MD Aaron Broman, MD Andrew Franklin, MD Department of Anesthesiology Division of Pediatric Anesthesiology Vanderbilt University School of Medicine and Monroe Carell Jr. Children’s Hospital at Vanderbilt Nashville, TN
The authors declare no conflict of interest. REFERENCES 1. Ai M, Heeger S, Bartels CF, Schelling DK. Clinical and molecular findings in osteoporosis-pseudoglioma syndrome. Am J Hum Genet. 2005;77:741–753. 2. Gong Y, Vikkula M, Boon L, et al. Osteoporosis-pseudoglioma syndrome, a disorder affecting skeletal strength and vision, is assigned to chromosome region 11q12–13. Am J Hum Genet. 1996;59:146–151. 3. Teebi AS, Al-Awadi SA, Marafie MJ, Bushnao RA, Satyanath S. Osteoporosis-pseudoglioma syndrome with congenital heart disease: a new association. J Med Genet. 1988;25:32–36. 4. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids. Anesthesiology. 2005;103:1079–1088.
FIGURE 1. Anteroposterior epidurogram.
5. Wilson GA, Brown JL, Crabbe DG, Hinton W, McHugh PJ, Stringer MD. Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? Paediatr Anaesth. 2001;11:65–70.
© 2014 American Society of Regional Anesthesia and Pain Medicine
Letters to the Editor
Defining Adductor Canal Block Accepted for Publication: December 4, 2013. To the Editor: e read with great interest the very thorough and well-executed article by Jæger et al concerning the comparison of the adductor canal block (ACB) versus the femoral nerve block for analgesia after total knee arthroplasty.1 However, we believe that some essential anatomical matters need to be addressed and clarified. The technique of the so-called ACB as described by the authors in the present and several previous articles consistently involved needle insertion halfway between the base of the patella and the anterior superior iliac spine (ASIS) under ultrasound to obtain a cross-sectional view of the femoral vessels and the saphenous nerve.1–4 Using an in-plane needle approach, a catheter was inserted via the needle, with the needle tip just lateral to the saphenous nerve lying lateral to the femoral artery, and 30 mL of ropivacaine 0.5% was injected via the catheter while visualizing sonographic expansion of the presumed adductor canal (AC). However, it is an anatomical matter of fact that the needle insertion point defined above is within the femoral triangle proximal to the AC. The AC extends from the apex of the femoral triangle to the adductor hiatus—and the apex of the femoral triangle is defined by the crossing of the medial margin of the adductor longus muscle and the medial margin of the sartorius muscle. The AC is a musculo-aponeurotic tunnel. It is roofed from the apex of the femoral triangle to the adductor hiatus by the vastoadductor membrane (VAM), which is a strong aponeurosis (also known as the anteromedial intermuscular septum or the subsartorial fascia) between the adductor longus and magnus muscles and the vastus medialis muscle. The sartorius muscle extends from the ASIS to the proximal medial surface of the tibia, and it runs anterior to the VAM. The AC is also known as the subsartorial canal, which might contribute to the confusion about the extent of the AC—considering that the sartorius muscle is the longest muscle in the body and much longer than the AC. The AC always contains the femoral vessels, the saphenous nerve, and the nerve to the vastus medialis muscle. The obturator nerve does often (but not always) enter the distal part of the AC and follows the femoral artery through the hiatus of the adductor magnus tendon to the popliteal
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Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
