RAPM Focus

Episode 25: Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial

In this episode of RAPM Focus, Dr. Brian Sites sits down with Daryl Henshaw, MD, and Christopher Edwards, MD, to discuss “Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial,” first published in June 2023.
Dr. Daryl Henshaw completed his medical school residency in regional anesthesia and acute pain fellowship training at Wake Forest. He is the associate vice chair of clinical operations at Atrium Health Wake Forest Baptist, the section head of regional anesthesia and acute pain management, and the medical director of acute pain services.
Dr. Christopher Edwards is a graduate of Louisiana State University Health Sciences at Wake Forest for both anesthesia and fellowship training in RAPM. He is the medical director for regional anesthesia and acute pain.
Dr. Henshaw and colleagues performed a prospective observational trial, where they asked the question if current guidelines to hold full anti-coagulation dose of Lovenox for 24 hours before surgery resulted in adequate anti-Xa level activity to support the performance of neuraxial or deep anesthetic type nerve block procedures. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Message from RAPM Editor–In–Chief, by Brian D. SITES

In this podcast episode, RAPM Editor-In-Chief Brian D. Sites discusses the massive growth opportunities in the exciting future of pain medicine. Sites highlights the importance that “anesthesiologists help define the value of medical interventions that we offer for pain management.”
As RAPM begins to receive more submissions relating to costs, Dr. Sites stresses how critical it is to understand how costs are factored into the interventions offered in health care, as costs can be prohibited. Dr. Sites hopes we may start to connect the dots to larger outcomes like the chronification of pain, mortality, major morbidity, extended length of stay, and more, as the interventions we offer can positively impact these outcome metrics. Watch the full podcast episode for more information.
For more on the World Day of Pain initiative, please see: https://esraeurope.org/meeting/1st-world-day-of-regional-anesthesia-pain-medicine/.

Episode 24: Incidence of persistent opioid use following traumatic injury

Data describing the relationship between specific traumatic injuries and opioid use is lacking, which is why RAPM is so delighted to support the work of Matthew Mauck, MD, PhD, and colleagues. In this episode of RAPM Focus, RAPM Editor-in-Chief Brian Sites, MD, discusses “Incidence of persistent opioid use following traumatic injury with Dr. Mauck, first published in June 2023.
Dr. Mauck is an assistant professor and vice chair of research for the University of North Carolina’s department of anesthesiology. He is a practicing pain physician, and his main research focus is on preventing the transition of acute to chronic pain following traumatic injury.
Upon individuals hospitalized after surgery, up to 60% continue to experience chronic pain at 12 months. Dr. Mauck and colleagues used insurance claims data from over a 20-year period to estimate the incidents of new persistent opioid use in three hospitalized trauma populations. Burn injury, motor vehicle collision, and orthopedic injury. New persistent opioid use is defined as the receipt of greater than one opioid prescription 90-180 days following injury in an individual with no opioid prescriptions during the year prior.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.
#opioidprescription
#opioiduse
#persistentopioiduse
#traumaticinjury
#regionalanesthesia
#acutepain
#chronicpain
#anesthesia
#pain
#painmanagement
#MedEd
#medicine

Episode 23: Real-world study of intranasal ketamine for use in patients with refractory chronic migraine

RAPM Editor-in-Chief Brian Sites, MD, joins Hsiangkuo Yua, MD, PhD, and Aniket Natekar, MD, twocoauthors of “Real-world study of intranasal ketamine for use in patients with refractory chronicmigraine,” first published in May 2023.Dr. Hsiangkuo Yuan received his medical degree from National Yang-Ming University in Taipei, Taiwan,and a PhD in biomedical engineering at Duke University. He joined Jefferson Headache Center in 2014 asa research fellow, then completed a neurology residency and headache fellowship at Thomas JeffersonUniversity. Dr. Yuan is currently an associate professor of neurology and the director of clinical researchat the Jefferson Headache Center. He is also the vice chair of ASRA Headache SIG and an associate editorof RAPM. His research interests include real world analysis of novel migraine therapeutics and afundamental understanding of CSF dynamics in patients with CSF high and low pressure headaches.Dr. Aniket Natekar pursued his medical education at the John A. Burns School of Medicine at theUniversity of Hawaii in Honolulu. He attended Thomas Jefferson University Hospital in Philadelphia,where he completed his residency in general neurology, and then a fellowship in headache medicine atthe Jefferson Headache Center. Dr. Natekar is currently a practicing neurologist with a subspecialtytraining in headache management.Migraine is a common and disabling headache disorder with huge societal implications in terms ofhuman suffering and loss of productivity. The World Health Organization recognizes its importance byranking it in seventh place among worldwide diseases causing disability. Refractory chronic migraineheadache is a subset condition of migraines. As the name suggests, it is an extremely unfortunatesituation with limited treatment options.*The purpose of this podcast is to educate and to inform. The content of this podcast does notconstitute medical advice, and it is not intended to function as a substitute for a healthcarepractitioner’s judgement, patient care, or treatment. The views expressed by contributors are those ofthe speakers. BMJ does not endorse any views or recommendations discussed or expressed on thispodcast. Listeners should also be aware that professionals in the field may have different opinions. Bylistening to this podcast, listeners agree not to use its content as the basis for their own medicaltreatment or for the medical treatment of others.Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.#headache#headachedisorder#migraine#refractorychronicmigraine#respiratorycomplications#intranasalketamine
#regionalanesthesia#chronicpain#anesthesia#pain#painmanagement#MedEd#medicine

Episode 22: Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors.

RAPM Editor-in-Chief Brian Sites, MD, joins Lei Xu, MD, and Ed Mariano, MD, MAS, FASA, FASRA, twocoauthors of “Rate of occurrence of respiratory complications in patients who undergo shoulderarthroplasty with a continuous interscalene brachial plexus block and associated risk factors,” firstpublished in May 2023.Dr. Xu is a clinical assistant professor in the department of anesthesiology at Stanford. She received hermedical degree from Stanford before completing her residency in anesthesiology at the University ofCalifornia San Francisco, and then a fellowship in regional anesthesia and acute pain medicine atStanford. She is interested in the application of regional anesthesia outside the operating room. Herresearch interests include studying the functional outcomes of clinical pathways that include regionalanesthesia in the primary arthroplasty in acute trauma populations.Dr. Mariano is a professor and senior vice chair in the department of anesthesiology at Stanford. He hasdeveloped techniques and patient care pathways to improve post-operative pain, patient safety, andother outcomes, and has published over 250 peer-reviewed articles. He has held leadership positions inthe California Society of Anesthesiologists, American Society of Anesthesiologists, American Society ofRegional Anesthesia and Pain Medicine, and multiple journal editorial boards.In their retrospective observational study, over 1,000 patients were evaluated undergoing total shoulderreplacement with a continuous interscalene block. Respiratory complications were categorized into fourgroups: none, mild, moderate, and severe. Interscalene blocks are important to the success of thesesurgeries, but there remain concerns about respiratory morbidity.*The purpose of this podcast is to educate and to inform. The content of this podcast does notconstitute medical advice, and it is not intended to function as a substitute for a healthcarepractitioner’s judgement, patient care, or treatment. The views expressed by contributors are those ofthe speakers. BMJ does not endorse any views or recommendations discussed or expressed on thispodcast. Listeners should also be aware that professionals in the field may have different opinions. Bylistening to this podcast, listeners agree not to use its content as the basis for their own medicaltreatment or for the medical treatment of others.Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.#interscalenebrachialplexusblock#interscaleneblock#respiratorymorbidity#respiratorycomplications#arthoplasty#shoulderarthoplasty
#localanesthetic#regionalanesthesia#chronicpain#anesthesia#pain#painmanagement#MedEd#medicine

Episode 21: Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty

RAPM Editor-in-Chief Brian Sites, MD, joins Daniela Bravo, MD, and Julián Aliste, MD, two co-authors of “Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip artholasty,” first published in February 2023. In this episode, they discuss the explosion of fascia PENG blocks in the past decade.
Dr. Bravo is an assistant professor in the department of anesthesiology and perioperative medicine at the University of Chile. She is the co-director of the regional anesthesia and acute pain service.
Dr. Julien Alaste is an associate professor at department of anesthesiology and perioperative medicine at the University of Chile. He is the director of the regional anesthesia and acute pain fellowship.
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.
#PENGblock
#arthoplasty
#localanesthetic
#regionalanesthesia
#chronicpain
#anesthesia
#pain
#painmanagement
#MedEd
#medicine

Episode 20: Violence in the pain clinic: the hidden pandemic

RAPM Editor-in-Chief Brian Sites, MD, joins Mercy A Udoji, MD, CMQ, FASA and Sudheer Potru, DO, FASA, FASAM, two coauthors of “Violence in the pain clinic: the hidden pandemic,” first published in August 2023 rapm-august 2023.pdf. Dr. Udoji is an associate professor of anesthesiology and pain medicine at Emory University School of Medicine.  Dr. Potru is a triple-board-certified anesthesiologist, interventional pain physician, and addiction medicine specialist with strong interest in both opioid safety and addiction. 

Episode 19: Hospital-Level Variability in Regional Nerve Block Administration by Race for Total Knee Arthroplasty

RAPM Editor-in-Chief Brian Sites, MD, joins Anjali A. Dixi, MD, the senior author of “Hospital-level variability in regional nerve block administration by race for total knee arthroplasty,” first published in December 2022 (https://rapm.bmj.com/content/early/2022/12/13/rapm-2022-104028). Dr. Dixi is from the Stanford University School of Medicine, in Stanford, CA.

Episode 18: ASRA Pain Medicine Guidelines on the Management of the Perioperative Patient on Cannabis

The political, professional, and cultural implications of using cannabinoids remain controversial despite its increased prevalence over the last 20 years. The American Society of Regional Anesthesia and Pain Medicine established a working group in November 2020 to review the evidence and knowledge gaps around cannabis use in the perioperative period and develop clinical recommendations for the management of patients using cannabis in this setting.
 
Authors Shalini Shah, MD, MBA, and Hance Clarke, MD, FRCPC, PhD, joined RAPM Editor-in-Chief Brian Sites, MD, to discuss committee’s findings, which were published in the article “ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids” in January 2023 (https://rapm.bmj.com/content/48/3/97).
 
The committee used a Delphi method with > 75% consensus to answer nine clinical questions. The members concluded that all surgical patients should be screened for cannabinoid use prior to surgery, heavy users be counseled on the negative effects on postoperative pain control, and surgery be postponed for patients who present with acute cannabis intoxication. They also advised that pregnant patients be educated on the risks of maternal cannabis on the fetus/neonate.
 
Dr. Shalini Shah is a professor and vice chair for the department of anesthesiology and director of perioperative services at the University of California at Irvine School of Medicine. She completed her residency in anesthesiology from Cornell University and a combined fellowship in adult and pediatric chronic pain at Harvard Medical School. She is the founder of the Pediatric Pain Program at UC Irvine and has previously served as associate program director for the pain medicine fellowship. Dr. Shah is the recipient of the ASRA Pain Medicine Chronic Pain Research Grant Award in 2017 for her landmark work in onabotulinumtoxinA (BOTOX®) use in pediatric migraine pain.
 
Dr. Hance Clarke is the director of pain services and the pain research unit at the Toronto General Hospital in Toronto, Canada. He is the knowledge translation chair for the University of Toronto Centre for the Study of Pain and an associate professor in the department of anesthesiology and pain medicine at the University of Toronto. Dr. Clarke has authored more than 150 peer-reviewed publications and has been invited to speak on pain control, cannabis, and the opioid crisis to the House of Commons in Ottawa, Canada, and elsewhere around the world.
 
*The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice, and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care, or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others.
 
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.

Episode 17: Impact of COVID-19 on Opioid Overdose and Other Adverse Events in the USA and Canada

The impact of the COVID-19 pandemic was especially challenging for vulnerable populations, such asthose with chronic long-term health conditions, mental health conditions, and substance use disorders.Lockdowns and fear of spread led to barriers for patients whether they were accessing methadonethrough opioid treatment programs or being prescribed buprenorphine.
A systematic review first published online in October 2022 sought to identify whether there was achange in opioid use and misuse outcomes during the COVID-19 pandemic. Authors Siddartha Simha,MD, and Mark C. Bicket, MD, PhD, joined RAPM Editor-in-Chief Brian Sites, MD, to discuss their article,“Impact of the COVID-19 pandemic on opioid overdose and other adverse events in the USA andCanada: a systematic review,” published October 2022 (https://rapm.bmj.com/content/48/1/37). Theauthors found that opioid-related emergency medicine use increased in most studies for both servicecalls and emergency department visits. Urine drug testing positivity results increased in all studies forfentanyl, and in most studies for heroin and oxycodone. Naloxone dispensation was unchanged anddecreased in one study. The authors concluded that efforts to curb the spread of COVID-19 aligned withan increase in the opioid crisis severity, which has implications for future pandemic responses.
Dr. Siddartha Simha is a third-year anesthesiology resident at Michigan Medicine in Ann Arbor. Originallyfrom Troy, MI, he obtained his medical degree from Oakland University William Beaumont School ofMedicine in Auburn Hills, MI. Dr. Simha has a strong interest in acute and chronic pain management andresearch with plans to pursue a clinical fellowship in pain medicine.
Dr. Mark C. Bicket is the co-director of the Opioid Prescribing Engagement Network and an assistantprofessor at the University of Michigan Medical School with a joint appointment in the School of PublicHealth. A clinician scientist and practicing physician, his work has been supported by the NationalInstitutes of Health, the Substance Abuse and Mental Health Services Administration, the Foundation forAnesthesia Education and Research, and the Patient-Centered Outcomes Research Institute.
*The purpose of this podcast is to educate and to inform. The content of this podcast does notconstitute medical advice, and it is not intended to function as a substitute for a healthcarepractitioner’s judgement, patient care, or treatment. The views expressed by contributors are those ofthe speakers. BMJ does not endorse any views or recommendations discussed or expressed on thispodcast. Listeners should also be aware that professionals in the field may have different opinions. Bylistening to this podcast, listeners agree not to use its content as the basis for their own medicaltreatment or for the medical treatment of others.
Podcast and music produced by Dan Langa. Find us on Twitter @RAPMOnline.