RAPM Focus

Episode 15: Anterior QL Block Does Not Reduce Opioid Consumption After Laparoscopic Hemicolectomy

Proponents of fascial plane blocks argue that their value can be found in opioid reduction and improvement of pain scores. On the other hand, critics argue that the effect size tends to be very small, amounting to a placebo. To address these conflicting ideas, a recent study examined the role of quadratus blocks and analgesia for laparoscopic hemicolectomy. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Jens Borglum, MD, PhD, the senior author of “Anterior quadratus lumborum block does not reduce postoperative opioid consumption following laparoscopic hemicolectomy: a randomized, double-blind, controlled trial in an ERAS setting,” first published in September 2022 (https://rapm.bmj.com/content/48/1/7). This fascinating study had 69 patients randomized to receive either an anterior quadratus lumborum block or isotonic saline, a placebo.
Dr. Jens Borglum is a consultant anesthetist, clinical research associate professor, and head of research at Zealand University Hospital, University of Copenhagen, Denmark. His main interests are ultrasound-guided nerve blocks and he is a prolific researcher and contributor to Regional Anesthesia & Pain Medicine. His clinical and research insights during the peer-review process are invaluable.
*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 14: Guidelines on Interventions for Cervical Spine (Facet) Pain from a Multispecialty Group

Guidelines hold great importance in pain medicine. With many interventional procedures, there is some evidence for efficacy, but wide variation in study results due to differences in technique, interpretation, and implementation. In this month’s RAPM Focus, Executive Editor Chad Brummett, MD, joins Steven Cohen, MD, the senior author of “Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group,” first published in November 2021 (https://rapm.bmj.com/content/47/1/3). These guidelines are a valuable resource for trainees, fellows, and anyone who works with them.
Dr. Steven Cohen is a professor of anesthesiology and critical care medicine, neurology, physical medicine and rehabilitation, and psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and Uniformed Services University of the Health Sciences in Baltimore, MD. He is also chief of pain medicine and director of pain operations at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center. He has published over 400 peer-reviewed articles and book chapters in journals such as Lancet, JAMA, BMJ, Canadian Medical Association Journal, Anesthesiology, Pain, and The New England Journal of Medicine. In addition to his academic work, Dr. Cohen is a retired colonel in the United States Army.
*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 13: Lumbar Medial Branch Blocks: How Does The Second Block Influence Progression?

For interventional procedures that involve implanting devices or ablating tissues, it is common for patients to undergo prognostic tests to determine if they are responders prior to moving on to permanent procedures. However, definitions of responders and the number of prognostic tests necessary has caused some confusion. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins David Provenzano, MD, and Jozef Leech, to discuss their study “Evaluation of lumbar medial branch blocks: how does the second block influence progression to radiofrequency ablation?,” first published in July 2022 (https://rapm.bmj.com/content/47/12/719). In a single-center retrospective review, 224 patients with two consecutive local anesthetic-only blocks were examined for pain relief.
Dr. David Provenzano is president-elect of the American Society of Regional Anesthesia and Pain Medicine. He is currently an adjunct associate professor at the University of Pittsburgh, is on the executive committee of the Western PA Surgery Center, and is a critical member of the editorial board at Regional Anesthesia & Pain Medicine.
Jozef Leech is a native of Johnstown, PA, and graduated from Washington & Jefferson College in 2020 with his Bachelor of Arts in biology. He completed 2 years of internship work with Dr. Provenzano at Pain Diagnostics and Interventional Care located in Pennsylvania. In August of 2022, Jozef started Kent State University College of Podiatric Medicine in Independence, OH. He is an active member with the American College of Foot and Ankle Surgeons.
*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.

Episode 12: Association of Perioperative Anxiety and Postoperative Opioid-Related Outcomes

The International Association for the Study of Pain defines pain as: “An unpleasant sensory or emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
Among many other variables, mental health conditions play a critical role in determining the emotional experience. Thus, it is very reasonable to hypothesize that baseline anxiety, for instance, may influence pain and opioid prescribing. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Shay Nguyen and Jennifer Waljee, MD, authors on “Prospective cohort study on the trajectory and association of perioperative anxiety and postoperative opioid-related outcomes,” first published in August 2022 (https://rapm.bmj.com/content/47/10/637). In this fascinating study, 1,771 patients were prospectively followed; self-reported opioid use, pain, and anxiety were recorded on the day of surgery and at 1-, 3-, and 6-months post-surgery to examine whether or not anxiety was a mediator between pain and opioid use.
Shay N. Nguyen is a fourth-year medical student at the University of Michigan who is applying into classic surgery. She studied biochemistry in the University of California, Santa Barba, where she did research in chemistry and material science. Currently, her research interests include understanding risk factors for opioid use in the context of surgery and perioperative anxiety management.
Dr. Jennifer F. Waljee is a plastic surgeon in academic practice at the University of Michigan. She completed her medical school training at Emory University and completed clinical residencies in general
surgery and plastic surgery at the University of Michigan, followed by a hand surgery fellowship. Dr. Waljee is a co-founder and co-director of the Michigan Opioid Prescribing Engagement Network (OPEN),
a statewide collaborative program dedicated to enhancing opioid stewardship and developing best practices for the management of acute pain during procedural care.
*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.

Episode 11: Effects of Hypnosis on Postoperative Opioid Use After Total Knee Arthroplasty

The International Association for the Study of Pain defines pain as: “An unpleasant sensory or emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Pain is both a disease and a symptom.” The inclusion of the word emotional in the definition alludes to the fact that consciousness is part of the pain pathway. Despite the knowledge that neurocognitive aspects of human psychology are intimately related to pain, very little research exists examining behavioral interventions. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Jessie Markovits, MD, the lead author of “Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial,” first published in June 2022
(https://rapm.bmj.com/content/47/9/534). In this provocative study, 64 patients got either a 10-minute hypnosis session or an enhanced control during a hospital medicine pre-op visit before total knee
arthroplasty.
Dr. Jessie Markovits completed medical school at Tulane School of Medicine in New Orleans, followed by an internal medicine residency at Stanford. Her current appointment is associate professor of
medicine, with a courtesy appointment to psychiatry and behavioral sciences at Stanford University. She is board-certified in internal medicine and has developed a perioperative specialization over the past 6 years in her clinical role as surgical co-management hospitalist, primarily for orthopedic surgery.
*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.

Episode 10: Quality of Meta-Analyses of Perioperative Interventions for Chronic Postsurgical Pain

Systematic reviews and meta-analyses are the main drivers of policy, evidence-based guidelines, and funding decisions, but many of them are fraught with errors, and the resources needed to peer-review
them are massive. A recent systematic review examined the quality of the current published meta-analyses in order to inform the design and reporting of future studies. In this month’s RAPM Focus,
Editor-in-Chief Brian Sites, MD, joins John Kramer MSc, PhD, the senior author of “Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review,” first published in January 2022 (https://rapm.bmj.com/content/47/4/263). The systematic review explored the idea that surgery may represent an environment, known as a transitional pain state, that could result in a patient developing chronic pain following surgery.
Dr. John Kramer is an associate professor in the faculty of medicine, department of anesthesiology, pharmacology and therapeutics, and principal investigator at ICORD at the University of British Columbia
in Vancouver, Canada. His lab is focused on improving outcomes for individuals with spinal cord injury and neuropathic pain.
*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 9: Role of Regional Anesthesia and Analgesia in Enhanced Recovery After Colorectal Surgery

In surgical care worldwide, there has been a growing trend towards enhanced recovery with the emphasis on early mobility, avoidance of unnecessary procedures and drug-induced side effects, and
faster return of normal gastrointestinal function, with the end result of shorter hospital stay. It’s natural to assume that regional anesthesiology and acute pain medicine would play a central role in enhanced recovery protocols for all of the well-described benefits. However, the base evidence is continually evolving as both anesthetic and surgical practices change.
In this month’s RAPM Focus, Associate Editor Edward Mariano, MD, joins Kariem El-Boghdadly, MBBS, BSc, FRCA, EDRA, lead author of an international collaboration in the regional anesthesiology and
enhanced recovery world, “Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials,” first published in March 2022
(https://rapm.bmj.com/content/47/5/282). Investigators carefully evaluated thirteen published randomized controlled trial studies involving 1,170 participants and concluded that regional analgesia
may only have modest evidence to support its inclusion in enhanced recovery protocols involving colorectal surgery patients.
Dr. Kariem El-Boghdadly is a consultant anesthetist at Guy’s and St. Thomas’ NHS Trust in London, and an editor of the journal Anesthesia. Dr. El-Boghdadly completed his undergraduate training at University College of London in 2007 and proceeded to undertake his anesthetic training in Southeast School of Anesthesia. He was awarded the Nuffield Prize for the fellowship of the Royal College of Anaesthetists and completed fellowships in prehospital medicine in Australia, followed by regional anesthesia in Toronto, Canada. Dr. El-Boghdadly is an honorary senior lecturer at King’s College London, and his research interests include regional anesthesia, airway management, and research delivery. He is a brilliant researcher and writer and is well-known for his work in the COVIDSurg Collaborative during the ongoing pandemic, and the ASRA-ESRA regional anesthesia nomenclature project.
*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 8: Postoperative Lidocaine Infusion Safety on Wards Without Continuous Cardiac Monitoring

Establishing new clinical pathways and accomplishing change often takes a super-human effort in a complex health system. In terms of systemic lidocaine, the analgesic effects of systemic lidocaine are well recognized, but what is novel is the application of this therapy in an environment once thought to be inappropriate, that is, in the general inpatient units. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Meagan Miller, APRN, MSN, AGACNP-BC, and Brian Allen, MD, to discuss their university-based study, “Safety of postoperative lidocaine infusions on general care wards without continuous cardiac monitoring in an established enhanced recovery program,” first published in January 2022 (https://rapm.bmj.com/content/47/5/320).
Meagan Miller graduated from the University of Alabama with her bachelor’s in nursing in 2012. She was then accepted into Vanderbilt University Medical Center Nurse Residency Program and joined the colorectal and general surgery floor, which sparked her interest in enhanced recovery after surgery, as it was the first floor to initiate lidocaine infusions outside of the ICU. She has her master’s in nursing science in adult gerontology acute care nurse practitioner and first assist.
Dr. Brian Allen is an associate professor at Vanderbilt University Medical Center, where he directs the fellowship in regional anesthesiology and acute pain medicine. He completed undergraduate in medical school at Washington University. He was a resident at Vanderbilt and did his regional fellowship at Oregon Health & Science University (OHSU) before returning to join the Vanderbilt faculty. His clinical focus is on regional and multimodal analgesia in ERAS pathways. His research interests include educational assessment, evaluating ERAS efficiency, efficacy and compliance, and opioid minimization.
*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 7: Language Analysis: A Comparison to Traditional Meta-Analysis in Hip and Knee Surgery

Systematic reviews and meta-analyses are incredibly important; they drive clinical practice, policy, and reimbursement, but unfortunately, take a team of people and a significant amount of time. In this month’s RAPM Focus, Editor-in-Chief Brian Sites, MD, joins Joshua Myszewski and Kristopher Schroder, MD, to discuss their exploratory study, “Evaluation of language analysis to summarize the literature: a comparison to traditional meta-analysis in primary hip and knee surgery,” first published in December 2021 (https://rapm.bmj.com/content/47/3/151). The study used something known as “sentiment analysis,” a computer-based tool, to evaluate 115 article abstracts from studies that were included in a recent systematic review and meta-analysis on total joint arthroplasty. The idea of the study was to evaluate if a sentiment analysis could come to similar conclusions as a full meta-analysis.
Joshua Myszewski is a second-year medical student at the University of Wisconsin School of Medicine. Since starting medical school, he’s been working on applying his previous engineering research experience to the clinical domain. He has an undergraduate background in engineering, and first began working with machine learning and artificial intelligence as an undergraduate. He has worked on the development of EEG-based brain computer interfaces for disabled patients.
Dr. Kristopher Schroeder is vice-chair of faculty development at the University of Wisconsin. Within ASRA Pain Medicine, he has served as the Editor for the ASRA Pain Medicine News from 2018-2021 and was honored to be one of the founding members of the Physician Mentorship and Leadership Development Special Interest Group. He assisted his wife, veterinarian Carrie Schroeder, in performing the first-ever recorded transversus abdominis plane (TAP) block on a lynx.
*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 6: Neuraxial & General Anesthesia for TJA Show Similar Rates of Perioperative Complications

The impact of the type of anesthesia on perioperative outcomes has been the subject of much debate. Observational data suggests that neuraxial anesthesia may provide benefits over general anesthesia, especially in the orthopedic population; however, it remains unclear if these benefits can be materialized in all subpopulations. In this month’s RAPM Focus, Executive Editor Stavros Memtsoudis, MD, PhD, interviews Edward Yap, MD, the first author of “Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study,” first published online in January 2022 (https://rapm.bmj.com/content/47/5/294). The study used introspective data from cases performed in 21 centers in the Kaiser Permanente Northern California system between 2017-2019, with the primary goal to compare perioperative outcomes between procedures performed with neuraxial anesthesia and general anesthesia.
Dr. Yap is a senior physician and anesthesiologist with the Kaiser Permanente South San Francisco Medical Group and a volunteer assistant professor with the University of California San Francisco.
*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.