Unusual clinical course Background:Regional nerve blocks ideally provide safe and effective post-operative pain control, decrease opiate requirements, and enhance recovery from intense pain following major thoracic, abdominal, and musculoskeletal surgeries. The erector spinae plane block, a recently described novel treatment for chronic neuropathic pain and acute pain after thoracic surgery, can be performed with in plane infiltration and placement of a continuous infusion catheter deep to the erector spinae muscle at the tip of the transverse process, resulting in diffusion of local anesthetic between vertebrae and the paravertebral space with sensory blockade of spinal nerves as well as sympathetic branches. Case Report:We describe the novel use of the erector spinae block for primary pain control and uncomplicated catheter removal in the setting of anticoagulation following a major hepatectomy for intrahepatic cholangiocarcinoma. The use of the erector spinae block in this context provided effective post-operative analgesia. Conclusions:Additional evidence from clinical trials will be helpful to evaluate the role of this relatively new block for perioperative analgesia.

Care management study, level IV.

Purpose of reviewAdvances in the treatment of septic shock have historically focused on resuscitation endpoints, mainly mean arterial pressure and cardiac output. As the definitions of sepsis and septic shock have shifted to focus on the diversity of causes of dysregulated host-response we have seen an emerging phenotype where tissue hypoxia persists despite adequate macrocirculatory parameters. Interest in the topic of microcirculation is re-emerging as validated bedside techniques for hemodynamic monitoring, such as video microscopes, are becoming available. We review the current understanding of how sepsis induced hypoperfusion with a focus on recent advances in monitoring the microcirculation, and how a proliferation of biomarkers and emerging therapeutic targets may impact future research. Recent findingsConventional hemodynamic monitoring systems fail to assess the microcirculation, and it's response to treatment. Lactate and venous oxygen saturations often drive biomarker-guided sepsis management. Visual assessments such as mottling and capillary refill time are often associated with predicting outcomes, but sometimes can have issues with inter-provider reliability. Microcirculatory damage can be observed sublingually and appears to have prognostic value. SummarySepsis is associated with changes in the microcirculation that can lead to tissue hypoxia and organ dysfunction. Further studies are needed to validate the usefulness of microcirculatory bedside tools in guiding resuscitative efforts.