Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, nonpharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.

(J Clin Anesth. 2018;44:50–56) Standardized hospital protocols that address severe postpartum hemorrhage (PPH), or estimated blood loss >1500 mL following delivery, generally follow principles of empiric resuscitation, favoring early transfusion of high volumes of fresh frozen plasma, packed red blood cells, and platelets. However, it has been suggested that blood product resuscitation should be individualized and adjusted according to the results of point-of-care viscoelastic testing (PCVT). In the present study, the authors compared clinical outcomes [volume of transfused blood products, rate of volume overload, and rate of intensive care unit (ICU) admission] and hospital costs for patients with severe PPH managed with and without PCVT-guided transfusion protocol.

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Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.

A B S T R A C TQuantification of the drained volume is one of the difficulties involved in using weighing lysimeters. Typically, this volume is measured by accessing a moat at the base of a lysimeter. However, it is not feasible to install the moat in small devices. Thus, the aim of this study involves developing, installing, calibrating, and checking the efficiency of small weighing lysimeters with automated drainage systems to test their functionality in field conditions. Each lysimeter is composed of a round PVC water tank with a diameter of 1.22 m and a depth of 0.58 m that is placed over a metal frame with three electronic load cells with the nominal capacity of each cell corresponding to 500 kg. The drainage system is composed of a small reservoir with a volume of 10 L, a weighing structure composed of a load cell with a nominal capacity of 30 kg, and an automatic solenoid valve driven by a device coupled to a data logger that records the data from the lysimeter and from the drainage system. Two calibrations are performed for the lysimeter as well as the drainage system to obtain equations with significant correlations (R 2 > 0.9999). The drainage system was activated several times during the tests after receiving approximately 63.4 L of water from rainfall, and this in turn indicated a good performance. Construção e calibração de lisímetros de pesagem com sistema automático de drenagem R E S U M O Uma das dificuldades na utilização de lisímetros de pesagem é a quantificação do volume drenado. Usualmente, tal volume é medido por meio de um fosso de acesso em sua base, cuja instalação é inviável em lisímetros de pequenas dimensões. Assim, este trabalho objetivou desenvolver, instalar, calibrar e verificar a eficiência de lisímetros de pesagem com sistemas de drenagem automatizados testando sua funcionalidade no campo. Cada lisímetro foi composto de uma caixa d'água circular de PVC, com 1,22 m de diâmetro e profundidade de 0,58 m, montada sobre uma estrutura metálica com 3 células de carga cada uma com capacidade nominal de 500 kg. O sistema de drenagem foi formado por um pequeno reservatório com capacidade de 10 L, uma estrutura de pesagem composta por uma célula de carga com capacidade nominal de 30 kg e uma válvula solenoide acionada automaticamente por um dispositivo eletrônico acoplado a um datalogger, que registrou os dados de ambos, do lisímetro e do sistema de drenagem. Foram realizadas calibrações de dois lisímetros e sistema de drenagem, cujos resultados foram equações ajustadas com correlação significativa (R 2 > 0,9999) para ambos. Durante os testes, o sistema de drenagem foi acionado várias vezes após receber aproximadamente 63,4 L de água por precipitação, apresentando bom desempenho.

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.