Pain Management Pain Management

Topics in PAIN MANAGEMENT Vol. 32, No. 11 Current Concepts and Treatment Strategies June 2017 CONTINUING EDUCATION ACTIVITY Pain After Patient Positioning: Diagnosis, Prevention, and Management

Lopa Misra, DO, and Narjeet Khurmi, MD Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to: 1. Recognize cardiopulmonary effects caused by changes in positioning. 2. List risk factors for postoperative peripheral nerve injury. 3. Explain measures to prevent postoperative peripheral nerve injury. Key Words: Brachial plexopathy, Cardiopulmonary effects, Compartment syndrome, Peripheral nerve injury, Pressure point injury

lthough changes in perioperative positioning have often operative injuries may not be preventable or even explainable. Abeen thought to be the culprit in various postoperative Other factors that may result in injury and pain include altera- injuries, research indicates factors unrelated to positioning tions in hemodynamic parameters, improper padding, the type may also play a significant role. Furthermore, at times, post- of surgery, and surgical technique. Because a team approach is essential for accurate diagnosis and to minimize injury, all perioperative providers should be cognizant of the injuries In This Issue that can occur and that often can be prevented. This applies to CE Article: Pain After Patient Positioning: Diagnosis, anesthesiologists, certified registered nurse anesthetists, Prevention, and Management ...... 1 Dr. Misra is Assistant Professor, and Dr. Khurmi is Consultant, Putting Naloxone in the Hands of the People...... 8 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ 85054; E-mail: misra. ICYMI: In Case You Missed It ...... 9 [email protected]. CE Quiz ...... 11 The authors, faculty, and staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if News in Brief ...... 12 any) have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.

CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on May 31, 2018. CNE Accreditation Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. LWW, publisher of Topics in Pain Management, will award 1.0 contact hours for this continuing nursing education activity. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on June 30, 2019.

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CO-EDITORS surgeons, pain specialists, and our nonsurgical colleagues such as neurologists and internists. Elizabeth A.M. Frost, MD Problems may occur due to cardiopulmonary effects of posi- Professor of Anesthesiology tioning and during specific surgical procedures requiring Icahn School of Medicine at Mount Sinai supine, lithotomy, lateral, prone, Trendelenburg, and reverse New York, NY Trendelenburg positions. Pressure point injuries, peripheral nerve injuries, and compartment syndrome present special Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN considerations. Professor of Nursing University of Connecticut School of Nursing Cardiopulmonary Effects Storrs, CT Patient positioning for surgery is a compromise between the needs of the surgical team and structural and physiologic tol- erance of the anesthetized patient.1 ASSOCIATE EDITOR Many positions lead to adverse cardiopulmonary effects. Change in position from standing to supine causes blood pres- Anne Haddad sure and cardiac output to increase because of an increase in Baltimore, MD venous return from the lower extremities. Afferent baroreceptors located in the aorta are activated via cranial nerve X (vagus nerve) and cranial nerve IX (glos- EDITORIAL BOARD sopharyngeal nerve) located in the carotid sinuses, increasing Jennifer Bolen, JD parasympathetic nervous system impulses to the sinoatrial The Legal Side of Pain, Knoxville, TN node and the myocardium. The result is a decrease in heart rate, stroke volume, and cardiac output. Activation of compensatory low-pressure mechanoreceptors C. Alan Lyles, ScD, MPH, RPh University of Baltimore, Baltimore, MD located in the atria and ventricle decreases sympathetic nervous system outflow to skeletal muscles and the splanchnic vascular bed. Lastly, atrial reflexes are activated that regulate renal sympa- Stephen Silberstein, MD thetic nerve, plasma renin concentrations, atrial natriuretic Jefferson Headache Center, Philadelphia, PA

The continuing education activity in Topics in Pain Management is intended for clini- Steven Silverman, MD cal and academic physicians from the specialties of anesthesiology, neurology, psychia- try, physical and rehabilitative medicine, and neurosurgery as well as residents in those Michigan Head Pain and Neurological Institute, Ann Arbor, MI fields and other practitioners interested in pain management. Topics in Pain Management (ISSN 0882-5646) is published monthly by Wolters Kluwer Health, Inc. at 14700 Sahar Swidan, PharmD, BCPS Citicorp Drive, Bldg 3, Hagerstown, MD Pharmacy Solutions, Ann Arbor, MI 21742. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or Email [email protected]. Visit our website at lww.com. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Priority postage paid at Hagerstown, MD, and at additional mailing offices. GST registration number: P. Sebastian Thomas, MD 895524239. POSTMASTER: Send address changes to Topics in Pain Management, Syracuse, NY PO Box 1610, Hagerstown, MD 21740. Publisher: Randi Davis Subscription rates: Individual: US $339, international: $467. Institutional: US $768, international $894. In-training: US $148 with no CME, international $168. Single copies: $73. Send bulk pricing Marjorie Winters, BS, RN requests to Publisher. COPYING: Contents of Topics in Pain Management are protected by copyright. Reproduction, photocopying, and storage or transmission by magnetic or electronic Michigan Head Pain and Neurological Institute, Ann Arbor, MI means are strictly prohibited. Violation of copyright will result in legal action, including civil and/ or criminal penalties. Permission to reproduce copies must be secured in writing; at the newsletter website (www.topicsinpainmanagement.com), select the article, and click “Request Permission” under “Article Tools” or e-mail [email protected]. For commercial Steven Yarows, MD reprints and all quantities of 500 or more, e-mail [email protected]. For Chelsea Internal Medicine, Chelsea, MI quantities of 500 or under, e-mail [email protected], call 1-866-903-6951, or fax 1-410-528- 4434. PAID SUBSCRIBERS: Current issue and archives (from 1999) are now available FREE online at www.topicsinpainmanagement.com. Lonnie Zeltzer, MD Topics in Pain Management is independent and not affiliated with any organization, vendor UCLA School of Medicine, Los Angeles, CA or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All com- ments are for general guidance only; professional counsel should be sought for specific situations. Editorial matters should be addressed to Anne Haddad, Associate Editor, Topics in Pain Management, 204 E. Lake Avenue, Baltimore, MD, 21212; E-mail: [email protected]. Topics in Pain Management is indexed by SIIC HINARI and Google Scholar.

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peptide, and arginine vasopressin levels. Thus, blood pressure dispersion, thereby reducing pressure-related injuries.1 In is maintained during position changes in the awake state. On addition, the scapula, sacrum, coccyx, and calves are also the other hand, general anesthesia, muscle relaxation, and prone to pressure-induced injury, and care must be taken to positive-pressure ventilation blunt compensatory sympathetic pad them appropriately. nervous system cardiopulmonary responses, decreasing Less common complications include reported cases of alo- venous return. Similarly, use of regional anesthesia results in pecia in the supine position. Compression of hair follicles and sympathectomy and blunting of compensatory mechanisms.2 hypotension and hypothermia are thought to be causative fac- Changes in respiratory mechanics are also associated with tors.3 The authors examined patients who were noted to have alterations in position. Gas exchange is highly dependent on pain, swelling, and exudation of the occiput where it was sup- ventilation and perfusion balance.2 In patients who are anes- porting the weight of the head for prolonged periods. thetized but are breathing spontaneously, respirations—both Alopecia was seen between day 3 and day 28 postoperatively. the tidal volume and the functional residual capacity—are Preventative measures include careful use of head straps that decreased, whereas the closing volume is increased. The result hold face masks, use of soft head supports and pads, and fre- is an increase in atelectasis and intrapulmonary shunt.1 quent turning of the head during prolonged cases.3 Bony Mechanical ventilation with muscle relaxation may improve prominences are also known to succumb to injuries due to ventilation-perfusion mismatch by restoring minute ventila- ischemic necrosis, hypothermia, and vasoconstrictive hypo- tion and decreasing atelectasis. However, the diaphragm tension.4 develops an abnormal shape due to the loss of muscle tone, Brachial plexus injuries have also been attributed to posi- resulting in further ventilation-perfusion mismatch and there- tioning. They occur not only in the supine position but also in 1 fore lowering the Pao2. Providers must note that any position other positions. In the supine position, root injury may be due that limits diaphragmatic, chest wall, and/or abdominal wall to extreme lateral head turning, steep head-down position, and movement increases atelectasis and intrapulmonary shunt. situations in which the upper extremity at the wrist is fixed, Normally, ventilation depends on several factors including leading to worsening of a stretch injury when the head is diaphragmatic excursion and lung compliance, and the shape moved laterally away from the fixed wrist. and movement of the lung and thorax. Changing from stand- Similarly, when arms are extended and head rotation is ing to supine position, functional residual capacity decreases excessive, brachial plexus injury may occur. Brachial plexus due to cephalad displacement of the diaphragm. With this injury may also result from shoulder braces placed too medi- positional change, chest wall contribution to ventilation ally or too tightly. Prevention strategies include placement of decreases to 10%, from 30%.1 shoulder braces laterally over the acromioclavicular joint. However, in the prone position, the thoracic cage and pelvis Sternal retraction during cardiothoracic cases performed in assume much of the weight, allowing the abdomen to move the horizontal position has also led to brachial plexus injury.5 with respirations, thereby improving pulmonary function. Vander Salm et al5 reported cases of rib fractures and brachial Therefore, prone positioning is useful in patients with acute plexus injuries due to median sternotomies. They concluded respiratory distress syndrome, obese patients, and children. that the incidence of rib fractures and brachial plexus injuries Recent studies have shown that the prone position improves is directly proportional to the extent of rib displacement by ventilation-perfusion matching in the posterior aspects of the retractors. lung as compared with the supine position.1 Another study examined 200 patients undergoing cardiac Supine Position surgery via a median sternotomy and the incidence of postoperative neuropathy.6 Results showed that there was a 10% The supine position, along with its variations, such as con- incidence of upper extremity neuropathy, unrelated to internal toured or lawn chair position, is the most frequently used mammary artery harvest, internal jugular vein catheterization, position during surgery. The horizontal/supine position pre- or left upper extremity position. Surgical manipulation and disposes patients to backache and pressure point injury to the sternal retraction were deemed causative factors. occiput, elbows, and heels. Padding of the lumbar spine aids Long thoracic nerve dysfunction has also been reported in in alleviating postoperative backache.2 the supine position.7 Although this dysfunction is often attrib- Ligamentous relaxation due to general anesthesia and cen- uted to patient positioning, experts have noted that trauma is a tral blocks results in a loss of physiologic lordosis of the lum- more likely cause. In the absence of trauma, long thoracic bar spine, leading to backache. Hyperextension of the lumbar nerve injury is likely a result of coincidental neuropathy or spine must be avoided to mitigate spinal nerve ischemia and perhaps due to a viral illness. This dysfunction presents as resulting paraplegia. Hyperextension/hyperlordosis of the “winged scapula” due to serratus anterior muscle injury.7 lumbar spine may occur when operating room tables are max- Along with brachial plexus and long thoracic nerve injuries, imally retroflexed, or when the kidney rest is raised. Proper other injuries associated with supine patient positioning padding of pressure points allows for point pressure include capsular shoulder injury, humerus fracture due to

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osteoporosis, and ulnar nerve injury at the level of the elbow Six risk factors have been identified by the American due to malpositioning of arm boards. Incorrect restraining Society of Anesthesiologists postoperative vision loss study arm strap placement may contribute to compression of the group. Those 6 risk factors include venous congestion of the anterior interosseous nerve and artery, resulting in ischemia of optic canal, use of the Wilson frame, increased intra-abdomi- neurovascular structures.2 nal pressure, prolonged case, male sex, and lower amounts of Perineal crush injury is another complication associated colloids.11 Blindness has also been noted after robotic prosta- with the supine position when the patient is placed on a frac- tectomy, head-down cases, and procedures with large crystal- ture table.8 Incorrect or inadequate padding of the vertical loid replacement and excessive positive fluid balance. pole exerts increased pressure on the pelvis, resulting in Other complications include decreased perfusion to the pudendal nerve damage and loss of penile sensation. carotid and vertebral arteries due to lateral rotation of the head and neck and stretch injuries to roots of the brachial Lateral Position plexus on the contralateral side, humeral head stretch injury, During lateral positioning, it is imperative for the team to and cubital tunnel compression.12 note that extreme flexion of the knees and hips can obstruct Ventilatory defects are also associated with the prone posi- blood flow to the popliteal and inguinal area, due to angula- tion. Abdominal compression may lead to increased intra- tion of vessels. An axillary roll is placed to relieve pressure to abdominal pressure, which can be higher than the venous the axillary artery, vein, and nerve. Proper padding of the pressure, resulting in pelvic and lower extremity perfusion common peroneal nerve of the dependent leg is essential. obstruction. Problems with hemostasis may also be seen. Along with ensuring proper spine alignment, there should be Because the vertebral venous plexuses are in direct communi- minimal circumduction of the dependent shoulder to avoid cation with abdominal veins, high intra-abdominal pressure stretch injury to the suprascapular nerve. transmits to the perivertebral and intraspinal surgical field, Variations of the lateral position include semisupine, semi- increasing venous distention and bleeding.1,13 prone, and flexed lateral positions. It is important to ensure that Trendelenburg Position the “up” arm is not hyperextended, has no traction, and is not compressed to prevent axillary neurovascular bundle damage.9 With the head-down position, the diaphragm moves ceph- Furthermore, the supporting bar must be well wrapped to alad, increasing the work of spontaneous ventilation and lead- avoid electrical grounding contact with the patient.1 Lateral ing to cranial congestion due to increased intracranial jack-knife or flexed lateral positions provide improved visuali- pressure. Stretch of the middle and lower divisions of the bra- zation during thoracotomy and some urologic surgical proce- chial plexus has also been reported.9 In addition, there is a dures by widening the intercostal spaces. However, the provider risk of hemodynamic alterations and a risk of the head and must remember that, due to the position of the feet below the neck sliding off the surgical table if the body is not well level of the heart, venous pooling and hypotension may occur. secured. In addition, a kidney rest may impair ventilation of the depend- Reverse Trendelenburg Position ent lung.1 Improper padding and ischemia from prolonged hypotension can cause eye and ear damage. Elevated intraocu- Complications of the head-up position include but are not lar pressure because of direct pressure, displaced lens, and cor- limited to: 10 neal abrasion has also been reported. Stretching of the long • Postural hypotension; thoracic nerve may result from extreme lateral neck flexion. • Air embolus; Prone Position • Facial, tongue, and neck edema; • Midcervical tetraplegia; and The prone position requires several precautions to avoid • Sciatic nerve injury.14 postoperative neuropathies and other complications. Safety measures include ensuring that the abdominal wall is Air travels to the heart and damages the ventricular contrac- free, a heightened awareness of venous and lymphatic stasis tion and conduction systems. Air may also travel to the pul- in the head, and the development of postoperative neck pain monary vessels, where it obstructs vessels and alters gas due to forced head rotation. In addition, cervical nerve root exchange.12 In patients with patent foramen ovales, air moves and vascular impingement have also been reported with to the left side of the heart and systemic circulation.12 extreme head rotation.2 The greater the degree of head elevation, the higher the Although this position has the advantage of improved surgi- chances of air embolus. Facial, tongue, and neck edema are a cal access, postoperative visual loss in prolonged cases is a result of excessive neck flexion in prolonged cases such as in grave complication. Therefore, extensive blood loss, posterior fossa and c-spine surgeries. conjunctival edema, and hemodynamic instability must be Midcervical tetraplegia is due to excess neck flexion stretch- promptly recognized and treated. ing the spinal cord, compromising vascular supply.1 Paralysis

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usually occurs below the C5 vertebra. Lastly, sciatic nerve brachioradialis from tight jewelry, watch bands, or arm straps. injury presents as foot drop and occurs when the hip is hyper- Motor deficits are usually not present in radial nerve injury. flexed without appropriate knee flexion.1 However, sensory deficits include numbness and tingling in the radial half of the dorsum of the hand and the dorsal aspect Compartment Syndrome 1 19 of the radial 3 /2 digits, excluding nail beds. Of note, if the Compartment syndrome may be associated with any surgical patient has a ring in place, finger ischemia due to swelling position. Ischemia, hypoxic edema, increased tissue pressure from excessive fluid administration may develop. in fascial compartments of the lower extremity, and rhabdomy- olysis all may cause compartment syndrome. The increased Median Neuropathy swelling of muscles leads to neurovascular compromise. The median nerve emerges from the lateral and medial cords Specific positioning-related factors in compartment syn- of the brachial plexus and is derived from C5-C7 (lateral cord) drome include hypotension, vascular obstruction from retrac- and C8-T1 (medial cord).16,17 Injury to the median nerve is tors, excessive knee and hip flexion, and popliteal pressure. In usually secondary to iatrogenic trauma and generally afflicts addition, tight extremity straps and leg wrappings can predis- men between 20 and 40 years of age, due to their inability to pose patients to compartment syndrome in the lower extremi- completely extend their elbows. While under general anesthe- ties. Excessive arm straps or draw sheets may result in sia, the elbow is sometimes inadvertently forced into exten- anterior interosseous nerve and artery compression and cause sion, resulting in a stretch injury of the median nerve.4,9,20 development of compartment syndrome.15 Symptoms of median nerve injuries depend on the location Appropriate diagnosis and treatment of compartment syn- of injury, causing both motor and sensory deficits. Median drome require heightened awareness and a high index of sus- nerve injuries above the elbow are primarily due to supracon- picion. Pain often presents out of proportion to what would be dylar humerus fractures. Median nerve injuries at or above the expected with the initial injury. Further signs include paresthe- elbow give rise to motor deficits that include loss of pronation sia, paralysis, pallor, and lack of pulse in an extremity. of the forearm, weakness in flexion of the hand at the wrist, Treatment includes decreasing tissue pressure, enhancing loss of flexion of the radial half of digits and thumb, and loss blood flow, and minimizing functional and tissue damage. of abduction/opposition of the thumb. Surgical fasciotomy may be necessary for definitive treatment. Occasionally, an “ape hand” abnormality develops when the hand is at rest, due to hyperextension of the index finger and Postoperative Peripheral Neuropathies thumb and an adducted thumb (Figure 1). Several neuropathies may result from inappropriate positioning. Radial Neuropathy The radial nerve emerges from the posterior cord of the brachial plexus and originates from the C6-C8 and T1 nerve roots.16,17 Injury to the radial nerve occurs due to compression against the bone at the musculospiral groove and the lateral arm proximal to the lateral epicondyle of the humerus.4 Patients under general anesthesia may experience compression from rigid structures such as arm boards, the edge of the operating table, or IV poles. Excessive cycling of an automated blood pressure cuff, in addition to tight sheets or towels used to secure arms, has been implicated in radial nerve injuries at the midhumeral level.9 Furthermore, upper extremity support devices such as slings or arm boards may cause radial nerve injury in the lateral position.4,18 Symptoms of a radial nerve injury depend on the site of injury. If the nerve is injured in the axillary region, the predom- inant symptom is triceps muscle weakness and an inability to extend the arm at the elbow, in addition to wrist drop.16,19 Sensory deficits include loss of sensation in the lateral arm, posterior forearm, the radial half of dorsum of hand, and the dorsal aspect of the lateral 3-and-a-half digits, excluding nail beds.19 Radial nerve injuries at the distal forearm may be due to Figure 1. Ape hand (median nerve nerve entrapment beneath the tendinous insertion of the injury).

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Another motor deficit seen in patients with median nerve External compression is commonly seen when the upper injury is the “benediction sign” when they attempt to form a extremity is outstretched and pronated. With this setup, the fist. In the benediction sign, the forefinger and thumb do not ulnar nerve can be very superficial—leaving it relatively fully flex. Sensory deficits include loss of sensation in lateral unprotected by overlying soft tissue. In addition, a distally dis- digits, including nail beds and the thenar area.20 placed automated blood pressure cuff may contribute to ulnar Median nerve injuries within the wrist are typically referred neuropathy because of compression.9 to as carpal tunnel syndrome. Excessive IV fluids periopera- Patient-related risk factors include male sex, obesity (body tively can lead to increased swelling and edema under the tran- mass index >38) and prolonged bed rest postoperatively.20 scarpal ligament, compressing nerves in the carpal tunnel.9 Injury of the ulnar nerve at the elbow causes motor deficits, Motor deficits in carpal tunnel syndrome include weakness in including weakness in flexion of the hand at the wrist, loss of flexion of the radial half of digits and the thumb and weakness flexion of the ulnar half of digits or the fourth and fifth digits, in abduction and opposition of the thumb. Compressive forces and loss of ability to cross the digits.9,19 Patients may have a can lead to the presence of an ape hand abnormality at rest or “claw hand” abnormality when the hand is at rest, due to hyper- the benediction sign when attempting to form a fist. Sensory extension of the fourth and fifth digits at the metacarpophalan- 1 16 deficits include numbness and tingling in the lateral 3 /2 digits geal joints and flexion at the interphalangeal joints (Figure 2). including nail beds, but excluding the thenar eminence, which is Sensory deficits include loss of sensation or paresthesia in supplied by the palmar cutaneous branch of the median nerve.21 the ulnar half of the palm and dorsum of hand, and the fourth and fifth digits on both palmar and dorsal aspects of the Ulnar Neuropathy hand.9 The ulnar nerve emerges from the medial cord of the brachial plexus and derives from C8-T1.16,17 It is the most com- Axillary Neuropathy monly injured nerve around the elbow at the level of the The axillary nerve arises from the posterior cord of the bra- cubital tunnel.9 chial plexus and originates from C5-C6.16 It travels through Most ulnar neuropathies present 48 hours postopera- the quadrangular space with the posterior circumflex humeral tively.9,18,20 Some common causes include excessive elbow artery and vein. Injury to the axillary nerve can occur due to flexion greater than 110 degrees and external compression excessive upper extremity abduction (>90 degrees), stretching without elbow flexion. Excessive elbow flexion may lead to the neurovascular bundle in the axilla—seen when patients narrowing of the cubital tunnel, which in turn increases the are in the prone or lateral position.9 potential for nerve compression in the tunnel.9 Axillary nerve palsies cause weakness and potentially paralysis of the teres minor and deltoid muscles, resulting in muscle wasting and loss of abduction of the upper extremity, in addition to weak flexion, extension, and rotation of the shoulder.9,16 Sensory loss is minimal and restricted to a small area over the lateral aspect of the upper arm.9,18 Management of Peripheral Neuropathies When a peripheral neuropathy is suspected, it is imperative that the physician perform a physical examination and docu- ment the assessment and associated findings. Early diagnosis and treatment results in resolution of the majority of peripheral nerve injuries, although at times, this may take months to years. The provider must also differentiate painful neuropathies from surgical causes of neuropathic pain. If a motor deficit is suspected, an electromyography (EMG) at baseline followed by a repeat EMG approximately 4 weeks later may provide crucial information for diagnosis and treatment. EMGs are extremely helpful in distinguishing between radiculopathies, plexopathies, and neuropathies. However, EMG will not aid in identifying the cause.1,22 A neurologic consultation is also invaluable. Figure 2. Claw hand (ulnar For anesthesia providers, nerve conduction studies may be nerve injury). more useful than EMG when assessing peripheral nerve

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injury. Nerve conduction studies evaluate both motor and 5. Vander Salm TJ, Cereda JM, Cutler BS. Brachial plexus injury sensory nerves. These tests are helpful in diagnosing a sub- following median sternotomy. J Thorac Cardiovasc Surg. 1980; 80(3):447-452. clinical polyneuropathy that may predispose individual nerves to injury. Moreover, such tests can differentiate between 6. Roy RC, Stafford MA, Charlton JE. Nerve injury and musculo- axonal injury and demyelination, which assists in prognosis. skeletal complaints after cardiac surgery: influence of internal mammary artery dissection and left arm position. Anesth Analg. Although sensory neuropathies are primarily transient, 1988;67(3):277-279. motor neuropathies include demyelination of the peripheral 7. Johnson RL, Warner ME, Staff NP, et al. Neuropathies after fibers of a nerve trunk and usually take anywhere from 4 to surgery: anatomical considerations of pathologic mechanisms. 6 weeks for recovery.1,15 Regardless of the type/cause of neu- Clin Anat. 2015;28(5):678-682. ropathy, a multidisciplinary approach is best when evaluating 8. Polyzois I, Tsitskaris K, Oussedik S. Pudendal nerve palsy in trauma and managing peripheral nerve injuries. and elective orthopaedic surgery. Injury. 2013;44(12):1721-1724. Treatment 9. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol. 2005;63(1):5-18. A variety of modalities are available for treatment of periph- 10. Malafa MM, Coleman JE, Bowman RW, et al. Perioperative cor- eral nerve injuries, including medications, physical therapy, neal abrasion: updated guidelines for prevention and management. and, if necessary, surgical intervention by a peripheral nerve Plast Reconstr Surg. 2016;137(5):790e-798e. specialist. The majority of sensory nerve injuries resolve 11. American Society of Anesthesiologists Task Force on Perioperative spontaneously over time. However, if a motor nerve injury is Visual Loss. Practice advisory for perioperative visual loss associ- present, one must focus on protecting the joints, ligaments, ated with spine surgery: an updated report by the American and tendons from further stress by placement of slings or Society of Anesthesiologists Task Force on Perioperative Visual splints or both if necessary. In addition, physical therapy plays Loss. Anesthesiology. 2012;116(2):274-285. a key role by strengthening the range of motion of affected 12. Rozet I, Vavilala MS. Risks and benefits of patient positioning joints and maintaining strength of the unaffected muscles. during neurosurgical care. Anesthesiol Clin. 2007;25(3):631-653. Nonsteroidal anti-inflammatory drugs and opioids, and 13. Spaeth J, Daume K, Goebel U, et al. Increasing positive end-expir- gabapentin and pregabalin, have been used successfully. atory pressure (re-)improves intraoperative respiratory mechanics Finally, if there is no resolution of nerve injury within 3 and lung ventilation after prone positioning. Br J Anaesth. 2016; 116(6):838-846. months, patients must be referred to a peripheral nerve sur- geon for further management. 14. Knight DJW, Mahajan RP. Patient positioning in anaesthesia. Continuing education in anaesthesia. Crit Care Pain. 2004;4(5): Conclusion 160-163. 15. Heitz JW. Limb paralysis. In: Heitz JW, ed. Post-anesthesia Care: Patient positioning for surgery is a balance between what is Symptoms, Diagnosis, and Management. Cambridge, England: necessary for access by surgeons and what is physiologically Cambridge University Press; 2016:162-172. safe for the patient. As demonstrated in this article, multiple 16. Winnie AP. Distribution of Brachial Plexus. In: Hakansson L, ed. issues may arise as a result of incorrect positioning. These Plexus Anesthesia: Perivascular Techniques of Brachial Plexus issues range from pain and vascular compromise to compart- Block. Vol. 1. Philadelphia, PA: W. B. Saunders Company; 1983: ment syndrome and peripheral nerve injuries. It is imperative 19-41. that clinicians promptly diagnose these complications to pro- 17. Tsui BCH, Rosenquist RW. Peripheral nerve blockade. In: Barash vide the most accurate management and the best chances for PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th successful resolution of injuries. ■ ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013:937-995. References 18. Zhang J, Moore AE, Stringer MD. Iatrogenic upper limb nerve injuries: a systematic review. ANZ J Surg. 2011;81(4):227-236. 1. Cassorla L, Lee J-W. Patient positioning and associated risks. In: Miller RD, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 19. Stoelting RK, Miller RD. Positioning and associated risks. Basics 8th ed. Vol. 1. Philadelphia, PA: Elsevier/Saunders; 2015:1240- of Anesthesia. 4th ed. New York, NY: Churchill Livingstone; 2000: 1265.e3. 196-208. 2. MacDonald JJ, Washington SJ. Positioning the surgical patient. 20. Warner MA. Perioperative neuropathies. Mayo Clin Proc. Anaesth Intens Care Med. 2012;13(11):528-532. 1998;73(6):567-574. 3. Abel RR, Lewis GM. Postoperative (pressure) alopecia. Arch 21. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical Dermatol. 1960;81:34-42. features, diagnosis, and management. Lancet Neurol. 2016;15(12): 1273-1284. 4. Warner ME. Patient positioning and potential injuries. In: Barash PG, Cullen BF, Stoelting RK, et al, eds. Clinical Anesthesia. 7th 22. Griffin MF, Malahias M, Hindocha S, et al. Peripheral nerve injury: ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams principles for repair and regeneration. Open Orthop J. 2014; & Wilkins; 2013:803-823. 8:199-203.

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Putting Naloxone in the Hands of the People

Anne Haddad movement among public health advocates seeks to put enforcement and first responders, as even skin contact with a Analoxone in the hands of anyone who will accept it to small amount of the drug can be dangerous. administer in case of an emergency, to save the life of some- Baltimore is a city known for homicide, literally: nonfiction one who has overdosed. book Homicide, by David Simon, and the TV series based on it. And at least one state has passed a law to start co-prescrip- In fact, more people die in Baltimore of opioid overdose than of tion of naloxone with certain opioids. homicide, notes Baltimore City Health Commissioner Leana S. Wen, MD, MSc, FAAEM, an emergency medicine physician. Many public health and government leaders have criticized Wen has been one of the most active champions of naloxone the companies for their increases, saying that increased sales access for community members. Since 2015, she has issued a would also lead to profits and would save far more lives. “blanket prescription” to all 620,000 residents of the city— anyone who could find himself A big challenge, however, has been the appearance of carfen- or herself in a position to save the life of someone who is tanil, a synthetic opioid used as a tranquilizing agent for ele- addicted to heroin or prescription opioid pain medicine. Wen’s phants and other large mammals. At 10,000 times more potent website claims that more than 800 lives have been saved than morphine and 100 times more potent than fentanyl, car- since then, by first responders, school nurses, police officers, fentanil has proven too strong for only one dose of naloxone. It and just regular people—friends and relatives of people who was first reported by the Drug Enforcement Administration in overdosed. the fall of 2016, and has appeared in certain states. Free 2-hour training programs were offered in the community, Huge increases in the price of the easy-to-use forms have but the training is no longer required. The Health Department’s not deterred the movement, as the crisis of overdose deaths website, www.dontdie.org, contains a 2-part training video, affects all demographic groups: longtime drug users inject- with Wen demonstrating use of the naloxone intranasal device. ing heroin, middle-class people whose addiction stems “I have used naloxone dozens of times in my practice, and from well-intentioned prescribing of pain medication, and I’ve seen how safe it is, how effective it is, and how easy to suburban kids whose recreational prescription drug abuse use,” Wen says during one of the training videos. has led unknowingly to fentanyl disguised as a less potent opioid. Cost Increases by Manufacturers Criticized Nowhere is naloxone access championed more vigorously Baltimore has been training people with the easy-to-use than in the US city with the oldest, continuously operating pub- intranasal form (made by Amphastar Pharmaceuticals). A lic health department–Baltimore, Maryland. The entire state, newer product that is even easier, but also costlier, is a 1-step like neighboring Virginia and Pennsylvania, has made the rever- cartridge (Evzio naloxone HCl injection, Kaléo). sal agent available essentially over the counter, without requiring Both companies have increased the prices of their drugs as a 2-hour training program for the person to administer it. demand has gone up. They claim that cost increases are As carfentanil reached Maryland in April, 3 deaths from needed for more research and development as naloxone overdose were reported in two suburban counties. Because the becomes used on a larger scale, but many public health and drug is so potent, health offcials have recommended provid- government leaders have criticized the companies for their ing multiple naloxone kits to individuals who ask for it, increases, saying that increased sales would also lead to prof- informing them that it might take several doses to revive its and would save far more lives. someone who has been exposed to carfentanil. The Baltimore City Health Department encourages commu- Authorities think the people using the drug did not know it nity members to attend public training programs to learn how to was carfentanil, so officials have mounted a public campaign recognize an opioid overdose, and how to respond. More than to warn the general public, especially groups most likely to 20,000 people who completed the training received a certificate, encounter it. Meanwhile, steps are being taken to protect law a prescription for naloxone, and a free kit containing naloxone.

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likelihood that someone “Looking more closely at non-fatal overdose cases will provide who is addicted to opioids can obtain treatment. a more accurate picture of the trends that contribute to fatal • Increasing access to nalox- overdoses and the opportunities to intervene and save lives.” one by requiring the state to establish guidelines for the co-prescription of medication. “Every patient who New State Law Expands Naloxone Access receives opioids has the potential to overdose,” Wen wrote. “Naloxone will save that person’s life, and so should be made In April, Maryland’s state legislature passed 2 new laws that available to the patient at the time they receive opioids.” greatly expanded efforts to reduce opioid deaths. Wen, the • Increasing hospital involvement to improve access to treat- Baltimore health commissioner, lauded the new bills and pre- ment. Under the new law, all hospitals will be required to sented on her website a summary of the most important have discharge protocols for patients who have overdosed changes, further summarized here: or have a substance use disorder. • Eliminating the training requirement for those obtaining • Allowing overdose fatality review committees to review nonfa- naloxone under a standing order. The previous law created tal overdose cases. “Surviving an overdose is one of the biggest burdensome paperwork requirements, Wen wrote. indicators that a person will die from a future overdose,” Wen • Expanding access to buprenorphine. Health centers and wrote. “Looking more closely at non-fatal overdose cases will systems will now be required to have providers on staff provide a more accurate picture of the trends that contribute to fa- who are able to prescribe buprenorphine, increasing the tal overdoses and the opportunities to intervene and save lives.” ■

ICYMI: IN CASE YOU MISSED IT

Notes from recent studies related to pain management, compiled by Elizabeth A.M. Frost, MD Identification of Biomarkers to regarding the predictive value of the third biomarker (adali- mumab trough level) could be questioned considering exten- Predict Dose Reduction of sive multiple testing in one study and disputed results in another.” Discontinuation of Biologic Further and better quality studies are indicated. (See Agents Used to Treat Tweehuysen L, van den Ende CH, Beeren FMM, et al. Little evidence for usefulness of biomarkers for predicting success- Rheumatoid Arthritis ful dose reduction or discontinuation of a biologic agent in rheumatoid arthritis: a systematic review. Arthritis Rheumatol. The original pool of 16 studies examined 52 biomarkers (17 2017;69(2):301-308. doi:10.1002/art.39946.) studied multiple times) for predictive value in dose reduction. In addition, the same pool of studies looked at 64 biomarkers for discontinuation of biologic treatment (33 studied multiple times). However, among the studies, only 3 biomarkers (adali- Is a Combination of Naproxen mumab trough level, Sharp/van der Heijde erosion score, and And Diazepam Effective in shorter symptom duration at the start of biologic treatment) could be identified that offered predictive value for dose Reducing Acute Lower Back reduction or discontinuation of a biologic agent for treating Pain? rheumatoid arthritis. Moreover, only 2 of the biomarkers (Sharp/van der Heijde A total of 114 patients were included in a randomized, dou- erosion score and shorter symptom duration at the start of ble-blind, comparative trial. Each patient scored 5 or more on biologic treatment) had a statistically significant association, the Roland-Morris Disability Questionnaire. Patients were albeit a weak one. The authors concluded: “Our findings administered naproxen 500 mg, to be taken twice daily for

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10 days. They were also randomized to either 28 tablets of Similarly, no significant differences were obtained in the diazepam 5 mg or placebo, to be taken as 1 or 2 tablets every secondary end points. Thus, the findings did not support the 12 hours as needed for low back pain. The primary end point routine use of combining prolonged subanesthetic ketamine was improvement in score between emergency department doses with opioids in posterior fusion surgery in children with (ED) discharge and 1 week later. Secondary outcomes included idiopathic scoliosis. (See Perello M, Artes D, Pascuets C, et al. pain intensity 1 week and 3 months after ED discharge. Prolonged perioperative low-dose ketamine does not improve Results showed that both groups, those randomized to nap- short and long-term outcomes after pediatric idiopathic scoliosis roxen and diazepam and those randomized to naproxen and pla- surgery. Spine [Phila Pa 1976]. 2017;42(5):E304-E312. cebo, had the same improvement of 11 from 5 for the mean doi:10.1097/BRS.0000000000001772.) Roland-Morris Disability Questionnaire score (95% confidence interval, 9–13). In the diazepam group, 18 of the 57 patients Nonpharmacologic Therapies reported moderate or severe low back pain, compared with 12 of the 55 patients in the placebo group at 1-week follow-up. For Low Back Pain: A At 3-month follow-up, 6 of the 50 patients taking diazepam Systematic Review for an reported moderate or severe low back pain, compared with 5 of the 53 placebo patients. Adverse events were reported by American College of Physicians 12 of 57 diazepam patients and 8 of 55 placebo patients. Clinical Practice Guideline The authors concluded that “diazepam should not be rou- tinely added to nonsteroidal analgesics for these patients.” Several nonpharmacologic therapies for primarily chronic (See Friedman BW, Irizarry E, Solorzano C, et al. Diazepam low back pain are associated with small to moderate, usually is no better than placebo when added to naproxen for acute short-term effects on pain. Other evidence suggests that mind- low back pain. Ann Emerg Med. 2017. doi:http://dx.doi. body interventions may also prove effective. org/10.1016/j.annemergmed.2016.10.002.) Chou et al performed a data search including Ovid MEDLINE (January 2008 through February 2016), Cochrane Routine Use of Subanesthetic Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists. They identified 9 Doses of Ketamine May Not randomized trials of nonpharmacologic options versus sham treatment, wait list, or usual care, or of 1 nonpharmacologic Provide Pain Relief For option versus another. Nonpharmacologic therapies ranged Children After Scoliosis from 2 (tai chi) to 121 (exercise). Tai chi (strength of evidence, low) and mindfulness-based stress reduction (moder- Surgery ate strength of evidence) are effective for chronic low back pain. These findings support previous studies regarding the Forty-eight pediatric patients aged 10 to 18 years with idio- effectiveness of yoga (also moderate). Other studies support pathic scoliosis were randomized to receive perioperative the effectiveness of exercise, psychological therapies, multi- low-dose ketamine or placebo for 72 hours. General anesthe- disciplinary rehabilitation, spinal manipulation, massage, and sia consisted of intraoperative remifentanil and morphine acupuncture for chronic low back pain. Only limited evidence postoperatively (patient-controlled analgesia). Postoperatively indicates that acupuncture is modestly effective for acute low morphine consumption, pain at rest and during movement back pain. The degree of pain benefit was small to moderate (coughing), undesirable effects, and sedation were assessed and generally short term; however, effects on function gener- and time to onset of oral intake, ambulation, and hospital ally were even less. (See Chou R, Deyo R, Friedly J, et al. stay. Peri-incisional hyperalgesia was measured at 72 hours. Systemic Pharmacologic Therapies for Low Back Pain: A Primary end point results (total cumulative morphine con- Systematic Review for an American College of Physicians sumption while admitted) were obtained in 44 patients. No sig- Clinical Practice Guideline. Ann Intern Med. 2017. nificant differences were detected between the 2 groups. doi:10.7326/M16-2458.)

Coming Soon:

• Pain Management in Hypermobility Syndromes: A Frequently Missed Cause of Chronic Pain

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Topics in Pain Management CE Quiz

To earn CME credit using the enclosed form, you must read the To earn nursing CNE credit, you must take the quiz online. Go to CME article and complete the quiz and evaluation assessment survey on www.nursingcenter.com, click on CE Connection on the toolbar at the the enclosed form, answering at least 70% of the quiz questions correctly. top, and select Browse by Journal. On the next page, select Topics in Select the best answer and use a blue or black pen to completely fill Pain Management. in the corresponding box on the enclosed answer form. Please indi- Log-in (upper right hand corner) to enter your username and cate any name and address changes directly on the answer form. If your password. First-time users must register. As a subscriber benefit, nurses name and address do not appear on the answer form, please print that can earn contact hours when taking CE activities from Topics in Pain information in the blank space at the top left of the page. Make a photo- Management for free. You must enter your subscription number in your copy of the completed answer form for your own files and mail the orig- registration profile where there is a field for Link to my subscription. inal answer form in the enclosed postage-paid business reply envelope. The 100% discount is applied when payment is requested. Non- Your answer form must be received by Lippincott CME Institute by subscribers pay a $49.00 fee to earn ANCC contact hours for this activity. May 31, 2018. Only two entries will be considered for credit. After log-in, locate and click on the CE activity in which you are Online CME quiz instructions: Go to http://cme.lww.com and click interested. There is only one correct answer for each question. A passing on “Newsletters,” then select Topics in Pain Management. Enter your score for this test is 7 correct answers. If you fail, you have the option of username and password. First-time users must register. After log-in, fol- taking the test again. When you pass, you can print your certificate of low the instructions on the quiz site. You may print your official certificate earned contact hours and access the answer key. For questions, contact immediately. Please note: Lippincott CME Institute, Inc., will not mail Lippincott Williams & Wilkins: 1-800-787-8985. The registration dead- certificates to online participants. Online quizzes expire on the due date. line for CNE credit is June 30, 2019.

1. Afferent baroreceptors located in the aorta are activa- 6. Ape hand abnormality occurs with injury to the ted by which of the following nerves? A. radial nerve A. Recurrent laryngeal nerve B. median nerve B. Vagus nerve C. ulnar nerve C. Glossopharyngeal nerve D. axillary nerve D. B and C 7. External compression of the ulnar nerve occurs with 2. Which one of the following parameters decreases as one A. outstretched upper extremity switches from upright to supine position? B. upper extremity supinated A. Atelectasis C. upper extremity pronated B. Closing volume D. A and C C. Functional residual capacity 8. Sensory deficit in a small area over the lateral aspect of D. Intrapulmonary shunt the deltoid is secondary to injury to 3. A 33-year-old man in otherwise good health reports A. radial nerve decreased sensation in the pelvic area after left lower B. humerus extremity fracture repair. Which of the following is a C. axillary nerve likely cause? D. median nerve A. Positioning on a fracture table 9. Radial nerve injury in the axilla can lead to B. Incorrect padding of the vertical pole of the fracture A. triceps muscle weakness table B. limited extension of the upper extremity at the elbow C. Pudendal nerve damage due to external compression C. wrist drop D. All of the above D. all of the above 4. Appropriate placement of a shoulder brace includes 10. Which of the following nerves has parts of its origin in placing it laterally over the acromioclavicular joint. the posterior cord of the brachial plexus? A. True A. Radial nerve B. False B. Axillary nerve 5. Positioning-related factors contributing to compart- C. Ulnar nerve ment syndrome include all of the following except D. A and B A. positioning-related hypotension B. blood pressures ranging from 112/50 to 130/60 mmHg C. excessive knee and hip flexion D. retractors resulting in vascular obstruction

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NEWS IN BRIEF

FDA Restricts Use of Codeine medicines due to the risk of serious adverse reactions in breastfed infants. These reactions in infants can include and Tramadol for Children excess sleepiness, difficulty breastfeeding, or serious breathing problems that could result in death. and Breastfeeding Mothers Source: www.fda.gov/Drugs/DrugSafety The FDA issued a restriction April 20, 2017, on the use of codeine and tramadol in children and in breastfeeding moth- HHS Funds State Grants ers. Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. The FDA also recommended Toward Opioid Addiction caution in youths older than 12. The action is a broader one Health and Human Services (HHS) Secretary Tom Price, than a 2013 restriction of use of codeine in children after MD, announced in an April 19, 2017, press release that his tonsillectomy. agency will provide $485 million in grants to help states “These medicines carry serious risks, including slowed or combat opioid addiction. The money will be administered difficult breathing and death, which appear to be a greater by the Substance Abuse and Mental Health Services risk in children younger than 12 years, and should not be Administration (SAMHSA). States and territories were used in these children. These medicines should also be lim- awarded funds based on rates of overdose deaths and unmet ited in some older children,” according to the statement need for opioid addiction treatment, according to a press released by the FDA. release from HHS. “Single-ingredient codeine and all tramadol-containing In the release, Price said this would be the first of 2 rounds products are FDA-approved only for use in adults. We are of grants. For the second round, he said, he would seek data also recommending against the use of codeine and tramadol and input from experts to develop policies and funding allo- medicines in breastfeeding mothers due to possible harm to cations that are “clinically sound” and effective. their infants,” according to the statement. According to the release, HHS has prioritized 5 specific As a result of this restriction, the FDA required several strategies to fight the opioid epidemic: strengthening public changes to the labels of all prescription medicines contain- health surveillance; advancing the practice of pain manage- ing codeine or tramadol. ment; improving access to treatment and recovery services; These new actions further limit the use of these medicines targeting availability and distribution of overdose-reversing beyond the FDA’s 2013 restriction of codeine use in children drugs; and supporting “cutting-edge” research. younger than 18 years to treat pain after tonsillectomy and/ The funding will be issued to all 50 states, the District of or removal of adenoids. Columbia, 4 US territories and the free associated states of To that restriction, the FDA is now adding: Palau and Micronesia. • The agency’s strongest warning, a contraindication, to “These grants aim to increase access to treatment, reduce the drug labels of codeine and tramadol alerting that, in unmet need and reduce overdose-related deaths,” Price said children younger than 12 years, codeine should not be in the press release. “I understand the urgency of this fund- used to treat pain or cough and tramadol should not be ing; however, I also want to ensure the resources and poli- used to treat pain. cies are properly aligned with and remain responsive to this • A new contraindication to the tramadol label warning evolving epidemic. Therefore, while I am releasing the against its use in children younger than 18 years to treat funding for the first year immediately, my intention for the pain after surgery to remove the tonsils and/or adenoids. second year is to develop funding allocations and policies • A new warning to the drug labels of codeine and tramadol that are the most clinically sound, effective and efficient. To to recommend against their use in adolescents between 12 that end, in the coming weeks and months, I will seek your and 18 years who are obese or have conditions such as assistance to identify best practices, lessons learned, and key obstructive sleep apnea or severe lung disease, which may strategies that produce measureable results.” increase the risk of serious breathing problems. Source: https://www.hhs.gov/about/news/2017/04/19/ • A strengthened warning to mothers that breastfeeding is trump-administration-awards-grants-states-combat-opioid- not recommended when taking codeine or tramadol crisis.html.

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