Entity

Time filter

Source Type

Seattle, WA, United States

Neal J.M.,Virginia Mason Medical Center
Regional anesthesia and pain medicine | Year: 2010

The role of ultrasound-guided regional anesthesia (UGRA) in reducing the frequency of regional anesthetic-related complications is difficult to ascertain from analyzing the limited literature on the topic. This evidence-based review critically evaluates the contributions of UGRA to improved patient safety, particularly as compared with standard nerve localization tools. Randomized controlled trials that compared UGRA with another form of neural localization and case series of more than 500 patients were used to compare safety parameters. The quality of studies and strength of evidence were graded. Of those randomized controlled trials identified by our search techniques, 22 compared the incidence of postoperative nerve symptoms, 17 assessed local anesthetic systemic toxicity parameters, and 3 studied hemidiaphragmatic paresis. Statistical proof for meaningful reduction in the frequency of extremely rare complications, such as permanent peripheral nerve injury, is likely unattainable. Although there is evidence for UGRA reducing the occurrence of vascular puncture and the frequency of hemidiaphragmatic paresis, as yet there is at best inconclusive scientific proof that these surrogate outcomes are linked to actual reduction of their associated complications, such as local anesthetic systemic toxicity or predictable diaphragmatic impairment in at-risk individuals. This evidence-based review thus strives to summarize both the power and the limitations of UGRA as a tool for improving patient safety. Source


Neal J.M.,Virginia Mason Medical Center
Regional Anesthesia and Pain Medicine | Year: 2011

The Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group develops and maintains guidelines for fellowship training in the subspecialty. These guidelines update the original guidelines that were published in 2005. The guidelines address 3 major topic areas: organization and resources, the educational program, and the evaluation process. Copyright © 2011 American Society of Regional Anesthesia and Pain Medicine. Source


Neal J.M.,Virginia Mason Medical Center
Regional Anesthesia and Pain Medicine | Year: 2016

In 2010, the American Society of Regional Anesthesia and Pain Medicine's evidence-based medicine assessment of ultrasound (US)- guided regional anesthesia (UGRA) analyzed the effect of this nerve localization technology on patient safety. That analysis focused on 4 important regional anesthesia complications: peripheral nerve injury, local anesthetic systemic toxicity (LAST), hemidiaphragmatic paresis (HDP), and pneumothorax. In the intervening 5 years, further research has allowed us to refine our original conclusions. This update reviews previous findings and critically evaluates new literature published since late 2009 that compares the patient safety attributes of UGRA with those of traditional nerve localization methods. As with the previous version of this exercise, analysis focused on randomized controlled trials that compared UGRA with an alternative neural localization method and case series of more than 500 patients. The Jadad score was used to grade individual study quality, and conclusions were graded as to strength of evidence. Of those randomized controlled trials identified by our search techniques, 28 compared the incidence of postoperative nerve symptoms, 27 assessed LAST parameters, 7 studied HDP, and 9 reported the incidence of pneumothorax. The current analysis strengthens our original conclusions that US guidance has no significant effect on the incidence of postoperative neurologic symptoms and that UGRA reduces the incidence and intensity of HDP but does so in an unpredictablemanner. Conversely, emerging evidence supports the effectiveness of US guidance for reducing LAST across its clinical presentation continuum. The predicted frequency of pneumothorax has grown smaller in tandem with increased experience with US-guided supraclavicular block. This evidence-based review summarizes both the power and the limitations of UGRA as a tool for improving patient safety. Copyright © 2016 by American Society of Regional Anesthesia and Pain Medicine. Source


Purpose To compare final spherical equivalent (SE) refractions in patients who previously underwent radial keratotomy (RK) undergoing routine cataract surgery using keratometry (K) values from the Tomey (Topographic Modeling System [TMS]; Tomey Corp., Phoenix, AZ) Placido topographer, manual keratometer, and IOLMaster (Carl Zeiss Meditec AG, Jena, Germany) keratometer using the Haigis formulas. Design Retrospective case series. Subjects A total of 26 RK eyes (20 patients) with a minimum of 3 months postoperative follow-up. Methods The following K values were evaluated: TMS topography (flattest K within first 9 rings, average K, minimum K), manual K, IOLMaster K. The final refractive goal was -0.50 diopters (D) for all eyes. The Haigis formula with target refraction -0.50 D was used. In addition, because of observed hyperopic overcorrections, IOLMaster K with the Haigis formula set to -1.00 D but with a final refractive goal of -0.50 D was also tested. The Haigis-L formula using IOLMaster K values was separately evaluated. Main Outcome Measures Mean final SE refraction, percent final SE within ideal (-0.12 to -1.00 D), acceptable (0.25 to -1.50 D), or unacceptable (<-1.50 or >0.25 D) range and within ±0.50 D and ±1.00 D of the intended result. Results Best results with minimal overcorrections were achieved with TMS flattest K (mean -0.68±0.60 D, 73% within ±0.50 D, and 88% within ±1.00 D of the surgical goal) and IOLMaster K set for target -1.00 D (mean -0.66±0.61 D, 69% within ±0.50 D, and 88% within ±1.00 D of the surgical goal). Other values produced more hyperopic (manual, IOLMaster K set for target -0.50 D, average topography) or higher myopic (minimum topography, Haigis-L) results. Conclusions For simplicity, using the IOLMaster K values combined with the Haigis formula set for target refraction -1.00 D produces acceptable results aiming for -0.50 D final SE refractions in former RK patients undergoing routine cataract surgery. © 2015 American Academy of Ophthalmology. Source


Neal J.M.,Virginia Mason Medical Center
Regional anesthesia and pain medicine | Year: 2010

OBJECTIVES: The American Society of Regional Anesthesia and Pain Medicine charged an expert panel to examine the evidence basis for ultrasound guidance as a nerve localization tool in the clinical practices of regional anesthesia and interventional pain medicine. METHODS: The panel searched, examined, and assessed the literature of ultrasound-guided regional anesthesia (UGRA) from the past 20 years. The qualities of studies were graded using the Jadad score. Strength of evidence and recommendations were graded using an accepted rating tool. RESULTS: The panel made specific literature-based assessments concerning the relative advantages and limitations of UGRA relative to traditional nerve localization methods as they pertained to block characteristics and complications. Assessments and recommendations were made for upper and lower extremity, neuraxial, and truncal blocks and include pediatrics and interventional pain medicine. CONCLUSIONS: Ultrasound guidance improves block characteristics (particularly performance time and surrogate measures of success) that are often block specific and that may impart an efficiency advantage depending on individual practitioner circumstances. Evidence for UGRA impacting patient safety is currently limited to the demonstration of improvements in the frequency of surrogate events for serious complications. Source

Discover hidden collaborations