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Albaum JM, Abdallah FW, Ahmed MM, Siddiqui U, Brull R. What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials. Clin Orthop Relat Res 2022; 480:2374-2389. [PMID: 36083846 PMCID: PMC10538904 DOI: 10.1097/corr.0000000000002367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials. QUESTIONS/PURPOSES In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery? METHODS We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate). RESULTS At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved. CONCLUSION When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Jordan M. Albaum
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Faraj W. Abdallah
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
| | - M. Muneeb Ahmed
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Urooj Siddiqui
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Mount Sinai Hospital, Toronto, ON, Canada
| | - Richard Brull
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
- Department of Anesthesia, Women’s College Hospital and Toronto Western Hospital, Toronto, ON, Canada
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Spitzer D, Wenger KJ, Neef V, Divé I, Schaller-Paule MA, Jahnke K, Kell C, Foerch C, Burger MC. Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients. J Clin Med 2021; 10:jcm10051013. [PMID: 33801401 PMCID: PMC7958619 DOI: 10.3390/jcm10051013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.
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Affiliation(s)
- Daniel Spitzer
- Institute of Neurology (Edinger Institute), University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany;
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Katharina J. Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany;
| | - Vanessa Neef
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany;
| | - Iris Divé
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany
| | - Martin A. Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Kolja Jahnke
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Christian Kell
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
| | - Michael C. Burger
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany; (I.D.); (M.A.S.-P.); (K.J.); (C.K.); (C.F.)
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany
- University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), 60596 Frankfurt, Germany
- German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, 60590 Frankfurt, Germany
- Correspondence: ; Tel.: +49-69-6301-87711
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Boselli E, Hopkins P, Lamperti M, Estèbe JP, Fuzier R, Biasucci DG, Disma N, Pittiruti M, Traškaitė V, Macas A, Breschan C, Vailati D, Subert M. European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia. Eur J Anaesthesiol 2021; 38:219-250. [PMID: 33186303 DOI: 10.1097/eja.0000000000001383] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.
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Affiliation(s)
- Emmanuel Boselli
- From the Department of Anaesthesiology, Pierre Oudot Hospital, Bourgoin-Jallieu, University Claude Bernard Lyon I, University of Lyon, France (EB), Leeds Institute of Medical Research at St James's School of Medicine, University of Leeds, Leeds, UK (PH), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Anaesthesiology, Intensive Care and Pain Medicine, University hospital of Rennes, Rennes, France (JPE), Department of Anaesthesiology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France (RF), Intensive Care Unit, Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (DGB), Department of Anaesthesiology, IRCCS Istituto Giannina Gaslini, Genova, Italy (ND), Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (MP), Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania (VT, AM), Department of Anaesthesia, Klinikum Klagenfurt, Austria (CB), Anaesthesia and Intensive Care Unit, Melegnano Hospital (DV) and Department of Surgical and Intensive Care Unit, Sesto San Giovanni Civic Hospital, Milan, Italy (MS)
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Lim JA, Sung SY, Lee JH, Lee SY, Kwak SG, Ryu T, Roh WS. Comparison of ultrasound-guided and nerve stimulator-guided interscalene blocks as a sole anesthesia in shoulder arthroscopic rotator cuff repair: A retrospective study. Medicine (Baltimore) 2020; 99:e21684. [PMID: 32871884 PMCID: PMC7458219 DOI: 10.1097/md.0000000000021684] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ultrasound-guided interscalene block (US-ISB) and nerve stimulator-guided interscalene block (NS-ISB) have both been commonly used for anesthesia in shoulder arthroscopic surgery.This study aims to compare which method provides surgical block as a sole anesthesia. In this retrospective study, 1158 patients who underwent shoulder arthroscopic rotator cuff tear repair surgery under ISB between October 2002 and March 2018 were classified into either the US-ISB or NS-ISB anesthesia groups. Demographic and anesthetic characteristics and intraoperative medications were analyzed after propensity score matching and compared between the 2 groups.There was a 0.5% rate of conversion to general anesthesia in the US-ISB group and a 6.7% rate in the NS-ISB group (P < .001). The volume of local anesthetics used for ISB was 29.7 ± 8.9 mL in the US-ISB group versus 38.1 ± 4.8 mL in the NS-ISB group (P < .001). The intraoperative use of analgesics and sedatives such as fentanyl, midazolam and propofol in combination was significantly lowered in the US-ISB group (P < .001).US-ISB is a more effective and safer approach for providing intense block to NS-ISB because it can decrease the incidence of conversion to general anesthesia and reduce the use of analgesics and sedatives during arthroscopic shoulder surgery.
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Affiliation(s)
- Jung A. Lim
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine
| | | | - Ji Hyeon Lee
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine
| | - So Young Lee
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine
| | - Sang Gyu Kwak
- Department of Medical Statistics, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Taeha Ryu
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine
| | - Woon Seok Roh
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine
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Hwang JT, Jang JS, Lee JJ, Song DK, Lee HN, Kim DY, Lee SS, Hwang SM, Kim YB, Lee S. Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2020; 28:2343-2353. [PMID: 31773201 DOI: 10.1007/s00167-019-05799-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 11/12/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Interscalene brachial plexus block (ISB) is one of the most commonly used regional blocks in relieving postoperative pain after arthroscopic rotator cuff repair. Dexmedetomidine (DEX) is an alpha 2 agonist that can enhance the effect of regional blocks. The aim of this study was to compare the effects of DEX combined with ISB with ISB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair. METHODS Fifty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single center, double-blinded randomized controlled trial study. Twenty-five patients were randomly allocated to group 1 and received ultrasound-guided ISB using a mixture of 1 ml (100 μg) of DEX and 8 ml of 0.75% ropivacaine preemptively. The other 25 patients were allocated to group 2 and underwent ultrasound-guided ISB alone using a mixture of 1 ml of normal saline and 8 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were checked within 48 h postoperatively. The plasma interleukin (IL)-6, -8, -1β, cortisol, and substance P levels were also measured within 48 h, postoperatively. RESULTS Group 1 showed a significantly lower mean VAS score and a significantly higher mean SAT score than group 2 at 1, 3, 6, 12, and 18 h postoperatively. Compared with group 2, group 1 showed a significantly lower mean plasma IL-6 level at 1, 6, 12, and 48 h postoperatively and a significantly lower mean IL-8 level at 1, 6, 12, 24, and 48 h postoperatively. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (12.7 h > 9.4 h, p = 0.006). CONCLUSIONS Ultrasound-guided ISB with DEX in arthroscopic rotator cuff repair led to a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h postoperatively than ISB alone. In addition, ISB with DEX showed lower mean plasma IL-6 and IL-8 levels than ISB alone within 48 h postoperatively, with delayed rebound pain. LEVEL OF EVIDENCE I. TRIAL REGISTRATION 2013-112, ClinicalTrials.gov Identifier: NCT02766556.
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Affiliation(s)
- Jung-Taek Hwang
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Republic of Korea
| | - Ji Su Jang
- Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical College, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 24253, Republic of Korea
| | - Jae Jun Lee
- Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical College, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 24253, Republic of Korea.
| | - Dong-Keun Song
- Department of Pharmacology, Hallym University Medical College, Chuncheon-si, Republic of Korea
| | - Han Na Lee
- Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical College, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 24253, Republic of Korea
| | - Do-Young Kim
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Republic of Korea
| | - Sang-Soo Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Republic of Korea
| | - Sung Mi Hwang
- Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical College, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 24253, Republic of Korea
| | - Yong-Been Kim
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Republic of Korea
| | - Sanghyeon Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si, Republic of Korea
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Complex issues in new ultrasound-guided nerve blocks: how to name, where to inject, and how to publish. J Anesth 2018; 32:283-287. [DOI: 10.1007/s00540-018-2452-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/06/2018] [Indexed: 12/18/2022]
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The concept of protective nerve stimulation for ultrasound guided nerve blocks. Med Hypotheses 2017; 107:72-73. [DOI: 10.1016/j.mehy.2017.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/14/2017] [Indexed: 11/18/2022]
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Wang ZX, Zhang DL, Liu XW, Li Y, Zhang XX, Li RH. Efficacy of ultrasound and nerve stimulation guidance in peripheral nerve block: A systematic review and meta-analysis. IUBMB Life 2017; 69:720-734. [PMID: 28714206 DOI: 10.1002/iub.1654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/22/2017] [Indexed: 11/06/2022]
Abstract
Evidence was controversial about whether nerve stimulation (NS) can optimize ultrasound guidance (US)-guided nerve blockade for peripheral nerve block. This review aims to explore the effects of the two combined techniques. We searched EMBASE (from 1974 to March 2015), PubMed (from 1966 to Mar 2015), Medline (from 1966 to Mar 2015), the Cochrane Central Register of Controlled Trials and clinicaltrials.gov. Finally, 15 randomized trials were included into analysis involving 1,019 lower limb and 696 upper limb surgery cases. Meta-analysis indicated that, compared with US alone, USNS combination had favorable effects on overall block success rate (risk ratio [RR] 1.17; confidence interval [CI] 1.05 to 1.30, P = 0.004), sensory block success rate (RR 1.56; CI 1.29 to 1.89, P < 0.00001), and block onset time (mean difference [MD] -3.84; CI -5.59 to -2.08, P < 0.0001). USNS guidance had a longer procedure time in both upper and lower limb nerve block (MD 1.67; CI 1.32 to 2.02, P < 0.00001; MD 1.17; CI 0.95 to 1.39, P < 0.00001) and more patients with anesthesia supplementation (RR 2.5; CI 1.02 to 6.13, P = 0.05). USNS guidance trends to result in a shorter block onset time than US alone as well as higher block success rate, but no statistical difference was demonstrated, as more data are required. © 2017 IUBMB Life, 69(9):720-734, 2017.
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Affiliation(s)
- Zhi-Xue Wang
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - De-Li Zhang
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Xin-Wei Liu
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Yan Li
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Xiao-Xia Zhang
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Ru-Hong Li
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
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Effects of arthroscopy-guided suprascapular nerve block combined with ultrasound-guided interscalene brachial plexus block for arthroscopic rotator cuff repair: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2017; 25:2121-2128. [PMID: 27311449 DOI: 10.1007/s00167-016-4198-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this study was to compare the pain relieving effect of ultrasound-guided interscalene brachial plexus block (ISB) combined with arthroscopy-guided suprascapular nerve block (SSNB) with that of ultrasound-guided ISB alone within the first 48 h after arthroscopic rotator cuff repair. METHODS Forty-eight patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled. The 24 patients in group 1 received ultrasound-guided ISB and arthroscopy-guided SSNB; the remaining 24 patients in group 2 underwent ultrasound-guided ISB alone. Visual analogue scale pain score and patient satisfaction score were checked at 1, 3, 6, 12, 18, 24, and 48 h post-operatively. RESULTS Group 1 had a lower visual analogue scale pain score at 3, 6, 12, 18, 24, and 48 h post-operatively (1.7 < 2.6, 1.6 < 4.0, 3.5 < 5.8, 3.6 < 5.2, 3.2 < 4.2, 1.3 < 2.0), and a higher patient satisfaction score at 6, 12, 18, 24, and 36 h post-operatively than group 2 (7.8 > 6.0, 6.2 > 4.3, 6.4 > 5.1, 6.9 > 5.9, 7.9 > 7.1). Six patients in group 1 developed rebound pain twice, and the others in group 1 developed it once. All of the patients in group 2 had one rebound phenomenon each (p = 0.010). The mean timing of rebound pain in group 1 was later than that in group 2 (15.5 > 9.3 h, p < 0.001), and the mean size of rebound pain was smaller in group 1 than that in group 2 (2.5 > 4.0, p = 0.001). CONCLUSION Arthroscopy-guided SSNB combined with ultrasound-guided ISB resulted in lower visual analogue scale pain scores at 3-24 and 48 h post-operatively, and higher patient satisfaction scores at 6-36 h post-operatively with the attenuated rebound pain compared to scores in patients who received ultrasound-guided ISB alone after arthroscopic rotator cuff repair. The combined blocks may relieve post-operative pain more effectively than the single block within 48 h after arthroscopic cuff repair. LEVEL OF EVIDENCE Randomized controlled trial, Level I. ClinicalTrials.gov Identifier: NCT02424630.
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A comparison of motor stimulation threshold in ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery: a randomized trial. Can J Anaesth 2015; 63:461-7. [DOI: 10.1007/s12630-015-0553-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 10/10/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022] Open
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Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. Cochrane Database Syst Rev 2015; 2015:CD006459. [PMID: 26361135 PMCID: PMC6465072 DOI: 10.1002/14651858.cd006459.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014. OBJECTIVES The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks SEARCH METHODS In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies. MAIN RESULTS We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block. AUTHORS' CONCLUSIONS There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety ResearchPointer Court 1, Ashton RoadLancasterUKLA1 1RP
| | - Anastasia Price
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterUK
| | - Kevin J Walker
- Ayr HospitalDepartment of AnaestheticsDalmellington RoadAyrAyrshireUKKA6 6DX
| | - Ken McGrattan
- Royal Preston HospitalDepartment of AnaestheticsSharoe Green Lane NorthFulwoodPreston, LancashireUKPR2 9HT
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterUK
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Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26361135 DOI: 10.1002/14651858.cd006459.pub3.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014. OBJECTIVES The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks SEARCH METHODS In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies. MAIN RESULTS We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block. AUTHORS' CONCLUSIONS There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.
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Affiliation(s)
- Sharon R Lewis
- Patient Safety Research, Royal Lancaster Infirmary, Pointer Court 1, Ashton Road, Lancaster, UK, LA1 1RP
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DUGER C, ISBIR AC, KAYGUSUZ K, KOL IOZDEMIR, GURSOY S, OZTURK H, MIMAROĞLU C. The importance of needle echogenity in ultrasound guided axillary brachial plexus block: a randomized controlled clinical study. Int J Med Sci 2013; 10:1108-12. [PMID: 23869186 PMCID: PMC3714386 DOI: 10.7150/ijms.6598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/18/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE In this study we aimed to compare the echogenic needles and the nerve stimulation addition to non-echogenic needles in ultrasound guided axillary brachial plexus block for upper extremity surgery. METHODS 90 patients were enrolled to the study. The patients were allocated into three groups randomly: Group E (n=30): ultrasound guided axillary block using echogenic needle, Group N (n=30): ultrasound guided axillary block using non-echogenic needle, Group NS (n=30): ultrasound guided axillary block using non-echogenic needle with nerve stimulator assistance. Duration of block procedure, mean arterial pressure, heart rate, pulse-oximetry, onset time of sensory and motor block, duration of sensory and motor block, time to first analgesic use, total need for analgesics, postoperative pain scores, patient and surgeon satisfaction scores were recorded. RESULTS Duration of block procedure values were lower in group E and NS, sensory and motor block durations, were significantly lower in group N. Sensorial and motor block onset time values were found lower in group NS but higher in group N. Patient and surgeon satisfaction scores were found lower in group N. CONCLUSION We conclude that ultrasound guided axillary block may be performed successfully using both echogenic needles and nerve stimulation assisted non-echogenic needles.
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Affiliation(s)
- Cevdet DUGER
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Ahmet Cemil ISBIR
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Kenan KAYGUSUZ
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Iclal OZDEMIR KOL
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Sinan GURSOY
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Hayati OZTURK
- 2. Department of Orthopedics, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Caner MIMAROĞLU
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
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Tsoumakidou G, Garnon J, Ramamurthy N, Buy X, Gangi A. Interest of electrostimulation of peripheral motor nerves during percutaneous thermal ablation. Cardiovasc Intervent Radiol 2013; 36:1624-1628. [PMID: 23665861 DOI: 10.1007/s00270-013-0641-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/08/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE We present our experience of utilizing peripheral nerve electrostimulation as a complementary monitoring technique during percutaneous thermal ablation procedures; and we highlight its utility and feasibility in the prevention of iatrogenic neurologic thermal injury. METHODS Peripheral motor nerve electrostimulation was performed in 12 patients undergoing percutaneous image-guided thermal ablations of spinal/pelvic lesions in close proximity to the spinal cord and nerve roots. Electrostimulation was used in addition to existing insulation (active warming/cooling with hydrodissection, passive insulation with CO2 insufflation) and temperature monitoring (thermocouples) techniques. Impending neurologic deficit was defined as a visual reduction of muscle response or need for a stronger electric current to evoke muscle contraction, compared with baseline. RESULTS Significant reduction of the muscle response to electrostimulation was observed in three patients during the ablation, necessitating temporary interruption, followed by injection of warm/cool saline. This resulted in complete recovery of the muscle response in two cases, while for the third patient the response did not improve and the procedure was terminated. No patient experienced postoperative motor deficit. CONCLUSION Peripheral motor nerve electrostimulation is a simple, easily accessible technique allowing early detection of impending neurologic injury during percutaneous image-guided thermal ablation. It complements existing monitoring techniques and provides a functional assessment along the whole length of the nerve.
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Affiliation(s)
- Georgia Tsoumakidou
- University Hospital of Strasbourg, 1 Pl. de l Hopital, 67000, Strasbourg, France.
| | - Julien Garnon
- University Hospital of Strasbourg, 1 Pl. de l Hopital, 67000, Strasbourg, France
| | - Nitin Ramamurthy
- University Hospital of Strasbourg, 1 Pl. de l Hopital, 67000, Strasbourg, France
| | - Xavier Buy
- University Hospital of Strasbourg, 1 Pl. de l Hopital, 67000, Strasbourg, France
| | - Afshin Gangi
- University Hospital of Strasbourg, 1 Pl. de l Hopital, 67000, Strasbourg, France
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