Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation

Background and Objectives Fascial plane blocks are rapidly emerging to provide safe, feasible alternatives to epidural analgesia for thoracic and abdominal pain. We define a new option for chest wall and upper abdominal analgesia, termed the rhomboid intercostal and subserratus plane (RISS) block. The RISS tissue plane extends deep to the erector spinae muscle medially and deep to the serratus anterior muscle laterally. We describe a 2-part proof-of-concept study to validate the RISS block, including a cadaveric study to evaluate injectate spread and a retrospective case series to assess dermatomal coverage and analgesic efficacy. Methods For the cadaveric portion of the study, bilateral ultrasound-guided RISS blocks were performed on 6 fresh cadavers with 30 mL of 0.5% methylcellulose with india ink. For the retrospective case series, we present 15 patients who underwent RISS block or RISS catheter insertion for heterogeneous indications including abdominal surgery, rib fractures, chest tube–associated pain, or postoperative incisional chest wall pain. Results In the cadaveric specimens, we identified staining of the lateral branches of the intercostal nerves from T3 to T9 reaching the posterior primary rami deep to the erector spinae muscle medially. In the clinical case series, dermatomal coverage was observed in the anterior hemithorax with visual analog pain scores less than 5 in patients who underwent both single-shot and continuous catheter infusions. Conclusions Our preliminary cadaveric and clinical data suggest that RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia. Accepted for publication March 10, 2018. Address correspondence to: Hesham Elsharkawy, MD, MBA, MSc, Department of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code E31, Cleveland, OH 44195 (e-mail: elsharh@ccf.org). H.E. has received unrestricted educational funding from PAJUNK (Norcross, GA) and consultant fees from Pacira Pharmaceuticals, Inc. Those companies had no input into any aspect of the present project design or manuscript preparation. The authors declare no conflict of interest. All images are created and used with permission of Cleveland Clinic Center for Medical Art and Photography. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Behavioural responses to environmental hypercapnia in two eusocial species of African mole rats

Abstract

Damaraland and naked mole rat are eusocial mammals that live in crowded burrows in which CO₂ is elevated. These species are thought to be highly tolerant of CO₂ but their behavioural responses to hypercapnia are poorly understood. We hypothesized that Damaraland and naked mole rats would exhibit blunted behavioural responses to hypercapnia and predicted that their activity levels would be unaffected at low to moderate (2–5%) CO₂ but increased at > 7% CO₂. To test this, we exposed Damaraland and naked mole rats to stepwise increases in environmental CO₂ (0–10%) and measured activity, exploratory behaviour, and body temperature. Surprisingly, we found that both species exhibited no differences in movement velocity, distance travelled, zone transitions (exploration), or body temperature at any level of environmental hypercapnia. Conversely, when carbonic anhydrase was inhibited with acetazolamide (50 mg kg⁻¹ intraperitonially, to increase whole-animal acidosis), exploration was significantly elevated relative to hypercapnic controls in both species at all levels of inhaled CO₂, and naked mole rat body temperature decreased in > 7% CO₂. We conclude that both species are largely non-responsive to environmental CO₂, and that this tolerance may be dependent on bicarbonate buffering at the level of the kidney or within the blood.

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What Should We Do About Habitual Caffeine Use in Athletes?

Abstract

Caffeine is a well-established ergogenic aid, demonstrated to enhance performance across a wide range of capacities through a variety of mechanisms. As such, it is frequently used by both athletes and non-athletes alike. As a result, caffeine ingestion is ubiquitous in modern society, with athletes typically being exposed to regular non-supplemental caffeine through a variety of sources. Previously, it has been suggested that regular caffeine use may lead to habituation and subsequently a reduction in the expected ergogenic effects, thereby blunting caffeine's performance-enhancing impact during critical training and performance events. In order to mitigate this expected performance loss, some practitioners recommended a pre-competition withdrawal period to restore the optimal performance benefits of caffeine supplementation. However, at present the evidence base exploring both caffeine habituation and withdrawal strategies in athletes is surprisingly small. Accordingly, despite the prevalence of caffeine use within athletic populations, formulating evidence-led guidelines is difficult. Here, we review the available research regarding habitual caffeine use in athletes and seek to derive rational interpretations of what is currently known—and what else we need to know—regarding habitual caffeine use in athletes, and how athletes and performance staff may pragmatically approach these important, complex, and yet under-explored phenomena.

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Juvenile Idiopathic Arthritis: A Focus on Pharmacologic Management

Juvenile idiopathic arthritis is a chronic condition that affects many pediatric patients. It is a prevalent disease and has become the most common rheumatologic disease of childhood. The condition encompasses multiple different forms of chronic arthritides classified based on the location and number of joints affected as well as the presence or lack of a number of different inflammatory markers. The exact etiology is unknown but is thought to be multifactorial with genetic, humoral, and environmental factors playing a key role.

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A Case Study of a Child With Mitochondrial Disease

A 4-year-old girl recently diagnosed with epilepsy presented to her pediatric advanced practice registered nurse (APRN) in a primary care clinic with 2 weeks of increased seizure activity after a medication change from carbamazepine to valproic acid. Symptoms also included a sudden increase in lethargy, ataxia, and drowsiness. She is co-managed by a pediatric neurologist for seizure control who was currently away from the office. Associated test results included a normal valproic acid level, elevated ammonia and liver function (Table 1), and an abnormal electroencephalogram reading; indicating a generalized process with ongoing focal-like features.

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The ACEs Connection

While we do not routinely publish book reviews in this Journal, there is one book that I would like to draw to your attention: The Deepest Well: Healing the Long-term Effects of Childhood Adversity by Dr. Nadine Burke Harris (Harris, 2018).

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Skin Deep: Simplifying Practice Guidelines for Children With Atopic Dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin disorder in children. Often called eczema, AD is a papulosquamous eruption often characterized by pruritus and then the typical distribution and morphology of the rash (Saavedra et al., 2013). Thus, an idiom often used by health care professionals to describe AD is "the itch that rashes." Two leading organizations jointly authored an update on AD in 2012 (Schneider et al., 2013), and a third published several guidelines for the management of AD (Eichenfield et al., 2013, 2014, 2015; Sidbury et al., 2014).

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