HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013.

This international consensus statement is the collaborative effort of three medical societies representing electrophysiology in North America, Europe, and Asian-Paciﬁc area: the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the Asia Paciﬁc Heart Rhythm Society. The objective of the consensus document is to provide clinical guidance for diagnosis, risk stratiﬁcation, and management of patients affected by inherited primary arrhythmia syndromes. It summarizes the opinion of the international writing group members based on their own experience and on a general review of the literature with respect to the clinical data on patients affected by channelopathies.

This document does not address the indications of genetic testing in patients affected by inherited arrhythmias and their family members. Diagnostic, prognostic, and therapeutic implications of the results of genetic testing are also not included in this document because this topic has been covered by a recent publication1 coauthored by some of the contributors of this consensus document, and it remains the reference text on this topic. Guidance for the evaluation of patients with idiopathic ventricular ﬁbrillation, sudden arrhythmic death …

https://www.heartrhythmjournal.com/article/S1547-5271(13)00761-3/pdf

Executive summary: HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes

A continuous peripheral nerve block, also termed "perineural local anesthetic infusion," involves the percutaneous insertion of a catheter adjacent to a peripheral nerve, followed by local anesthetic administration via the catheter, providing anesthesia/analgesia for multiple days or even months. Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of lightweight, portable pumps permits ambulatory infusion as well. This technique's most common application is providing analgesia after surgical procedures. However, additional indications include treating intractable hiccups; inducing a sympathectomy and vasodilation to increase blood flow after a vascular accident, digit transfer/replantation, or limb salvage; alleviating vasospasm of Raynaud disease; and treating peripheral embolism and chronic pain such as complex regional pain syndrome, phantom limb pain, trigeminal neuralgia, and cancer-induced pain. After trauma, perineural infusion can provide analgesia during transportation to a distant treatment center, or while simply awaiting surgical repair. Catheter insertion may be accomplished using many possible modalities, including nerve stimulation, ultrasound guidance, paresthesia induction, fluoroscopic imaging, and simple tactile perceptions ("facial click"). Either a nonstimulating epidural-type catheter may be used, or a "stimulating catheter" that delivers electrical current to its tip. Administered infusate generally includes exclusively long-acting, dilute, local anesthetic delivered as a bolus only, basal only, or basal-bolus combination. Documented benefits appear to be dependent on successfully improving analgesia, and include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic requirements, opioid-related side effects, and sleep disturbances. In some cases, patient satisfaction and ambulation/functioning may be improved; an accelerated resumption of passive joint range-of-motion realized; and the time until discharge readiness as well as actual discharge from the hospital or rehabilitation center achieved. Lastly, postoperative joint inflammation and inflammatory markers may be decreased. Nearly all benefits occur during the infusion itself, but several randomized controlled trials suggest that in some situations there are prolonged benefits after catheter removal as well. Easily rectified minor complications occur somewhat frequently, but major risks including clinically relevant infection and nerve injury are relatively rare. This article is an evidence-based review of the published literature involving continuous peripheral nerve blocks.

Continuous Peripheral Nerve Blocks: A Review of the Published Evidence

Objective:Toreviewthetechnicalimprovementsandchangesinmanagement that have occurred over 21 years, which have made the minimally invasive repair of pectus excavatum safer and more successful. Summary Background Data: In 1997, we reported our 10-year experience with a new minimally invasive technique for surgical correction of pectus excavatum in 42 children. Since then, we have treated an additional 1173 patients, and in this report, we summarize the technical modifications which have made the repair safer and more successful. Methods: From January 1987 to December 2008, we evaluated 2378 pectus excavatum patients. We established criteria for surgical intervention, and patients with a clinically and objectively severe deformity were offered surgical correction. The objective criteria used for surgical correction included computed tomography (CT) scans of the chest, resting pulmonary function studies (spirometry and/or plethysmography), and a cardiology evaluation which included echocardiogram and electrocardiogram. Surgery was indicated if the patients were symptomatic, had a severe pectus excavatum on a clinical basis

Twenty-One Years of Experience With Minimally Invasive Repair of Pectus Excavatum by the Nuss Procedure in 1215 Patients

Executive function is a collection of cognitive processes essential for higher order mental function. Processes involved in executive function include, but are not limited to, working memory, attention, cognitive flexibility, and impulse control. These complex behaviors are largely mediated by prefrontal cortical function but are modulated by dopaminergic, noradrenergic, serotonergic, and cholinergic input. The ability of these neurotransmitter systems to modulate executive function allows for adaptation in cognitive behavior in response to changes in the environment. Because of the important role these neurotransmitter systems play in regulating executive function, changes in these systems can also have a grave impact on executive function. In addition, polymorphisms in genes associated with these neurotransmitters are associated with phenotypic differences in executive function. Understanding how these naturally occurring polymorphisms contribute to different executive function phenotypes will advance basic knowledge of cognition and potentially further understanding and treatment of mental illness that involve changes in executive function. In this review, we will examine the influence of dopamine, norepinephrine, serotonin, and acetylcholine on the following measures of executive function: attention, cognitive flexibility, and impulse control. We will also review the effects of polymorphisms in genes associated with these neurotransmitter systems on these measures of executive function.

The neural and genetic basis of executive function: Attention, cognitive flexibility, and response inhibition

BACKGROUND:This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children.METHODS:We reviewed the departmental regional anesthesia registry and the medical records of conse

Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children.

BACKGROUND:The effect of clonidine on the duration of sensory blockade after peripheral nerve blockade is controversial. We evaluated the effects of clonidine on the duration of sensory and motor block and analgesia time in children who underwent a variety of peripheral nerve blocks.METHODS:We revie

The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children.

STUDY DESIGN A retrospective study of consecutive patients. OBJECTIVE The purpose of this study was to determine implementing an accelerated protocol could decrease our average hospital stay and what impact this had on postoperative pain management. SUMMARY OF BACKGROUND DATA To our knowledge, no prior studies have reviewed the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion. METHODS This is a retrospective review of all consecutive patients undergoing posterior spinal fusion (PSF) for AIS before (June 1, 2008-May 31, 2013 = traditional protocol) and after (June 1, 2013-October 22, 2014 = accelerated protocol) protocol implementation. Subjective response to the FACES Pain Intensity scale was collected for each postoperative day while in the hospital by the nursing staff. RESULTS There were 194 patients in the traditional pathway and 90 patients in the accelerated pathway. No significant differences in age at surgery, sex, or number of levels fused were present between the groups. Patients managed under the accelerated discharge had an average hospital stay of 3.7 days compared with 5.0 days for the traditional discharge (P < 0.001). There was no increased incidence of wound complications between the two groups [3.6% (7/194) vs. 3.3% (3/90), P = 0.91] or readmission [1.5% (3/194) vs. 4.4% (4/90), P = 0.213]. Hospital charges for postoperative care were significantly less in the accelerated discharge group than in the traditional group ($18,360 vs. $23,640, P < 0.0001). This corresponded to a 22% ($5280/$23,640) decrease in postoperative hospital charges. Patients had a small (<1 point change on FACES pain scale) but statistically significant increase in pain on postoperative days 2, 3, and 4 (P = 0.0001, P = 0.0079, P = 0.0076). CONCLUSION Accelerated discharge following PSF for AIS was associated with a 22% decrease in hospital charges in the postoperative period. LEVEL OF EVIDENCE 4.

Accelerated Discharge Protocol for Posterior Spinal Fusion Patients With Adolescent Idiopathic Scoliosis Decreases Hospital Postoperative Charges 22.

Background We evaluated the efficacy and safety profile of low-dose (4-5 mcg/kg) intrathecal morphine for postoperative pain management after various surgical procedures in children. Methods We reviewed the pain management service database and the medical records of patients who received low-dose intrathecal morphine for postoperative analgesia at The Children's Hospital of Philadelphia between October 2003 and March 2006. Patients had been prospectively followed for 24-48 h after the intrathecal morphine administration. Results The medical records of 187 patients were examined. The mean age was 5.6 +/- 5.1 yr (median 4.0, interquartile range [IQR] 1.0-10.0). The median maximum pain score during the first 24 h in patients evaluated by the FLACC score and in those evaluated by the numeric verbal rating scale, was 0 (IQR 0-3) and 0 (IQR 0-4), respectively. The mean time to first rescue opioid was 22.4 +/- 16.9 h (range: 0-48 h, 95% CI: 19.9-24.8 h). During the first 24 h after surgery, 70 patients (37%) did not receive any opioids (oral or IV). Of the 117 patients who received opioids, 59 (50%) were managed with oxycodone only. Pain was managed with ketorolac in 33% of patients, either alone (11%) or in combination with IV or oral opioids (22%). The incidence of nausea or vomiting, pruritus, and urinary retention was 32%, 37%, and 6% respectively. One patient had transient postdural puncture headache, while two patients received supplemental oxygen beyond the first 60 postoperative minutes to manage occasional episodes of hypoxemia. No severe respiratory depression requiring assisted ventilation or naloxone administration was observed. Conclusion We conclude that low-dose intrathecal morphine in the pediatric population can be a useful and safe adjunct for postoperative analgesia.

Low-dose intrathecal morphine for postoperative analgesia in children.

The mechanisms and sites of action of epibatidine-induced antinociception and side effects are poorly understood. The present study tested the hypothesis that the serotonergic dorsal raphe nucleus is a site of action of epibatidine. Behavioral responses of rats to hindpaw formalin injection were compared after direct administration of epibatidine into the dorsal raphe and after subcutaneous administration. Different groups of rats were injected with formalin into the rear paw after administration of either epibatidine (0.01, 0.015, 0.03, and 0.06 μg) in the dorsal raphe or epibatidine (2.5–5 μg/kg) subcutaneously. Assessment of pain related behavior was done evaluating the incidence of favoring, lifting, and licking of the injected paw in the different groups. Abnormal behavior (freezing) was also recorded. Epibatidine was at least 100 times more potent when administered into the dorsal raphe nucleus versus systemically, implicating this nucleus as a site of action of the analgesic effects of epibatidine. Thus, epibatidine (0.015, 0.03, and 0.06 μg) in the dorsal raphe resulted in a significant lower pain score in the second phase of the formalin test compared with control rats and was as effective as subcutaneous epibatidine. The analgesic effects of epibatidine were regionally selective in that administration of epibatidine within the periaqueductal gray area but outside the dorsal raphe area was not analgesic. The highest doses of intraraphe epibatidine (i.e., 0.03–0.06 μg) also produced “freezing” behavior immediately after injection, which was relatively short-lived compared with the analgesic effect. Together, the results implicate the dorsal raphe nucleus as a target for the analgesic and perhaps anxiogenic effects of epibatidine.

Giovanni Cucchiaro

Papers

Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children.

The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children.

Accelerated Discharge Protocol for Posterior Spinal Fusion Patients With Adolescent Idiopathic Scoliosis Decreases Hospital Postoperative Charges 22.

Low-dose intrathecal morphine for postoperative analgesia in children.

The Dorsal Raphe Nucleus as a Site of Action of the Antinociceptive and Behavioral Effects of the α4 Nicotinic Receptor Agonist Epibatidine