Use of Ultrasound-Guided Superficial Cervical Plexus Block for Pain Management in the Emergency Department

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 2-A Retrospective Study

Objective. Clavicle fracture fixation is commonly performed under general anesthesia due to the complex sensory innervation in this region which poses a challenge for anesthesiologists applying regional anesthetic (RA) techniques. In part 1 of this two-part study, we summarized the current literature describing various RA approaches in clavicle fractures and surgery. In our earlier scoping review, we surmised that a superficial or intermediate cervical plexus block (CPB) may provide analgesia for this procedure and, when combined with an interscalene brachial plexus block (ISB), can provide anesthesia to the clavicular region for surgical fixation. We performed a retrospective study, consolidating assumptions that were based on the results of our earlier scoping review. Methods. A retrospective study was conducted on 168 consecutive patients who underwent clavicle fixation surgery at a tertiary healthcare system in Singapore. We used a standardized pro forma to collate perioperative data from the electronic health records of both hospitals, including anesthetic technique, analgesic requirements, pain scores, and adverse events, up to the second postoperative day or up until discharge. Results. In our study, patients who received RA had significantly reduced pain scores and opioid requirements, compared to general anesthesia (GA) alone. Through subgroup analysis, differences were found in postoperative pain scores and opioid requirements in the following order: GA alone > GA with local infiltration analgesia > CPB > CPB plus ISB. All patients who received combined CPB and ISB had upper limb weakness in recovery, compared to none with CPB alone (p < 0.001). Of those who received an ISB either in isolation or combined with a CPB, four (9.3%) were reported to have dyspnea (within 24 h) and motor weakness that persisted beyond 12 h, compared to none for patients that received CPB alone. Conclusions. Addition of a CPB to GA for clavicle fracture fixation surgery is associated with reduced pain scores in the early postoperative period, with a lower opioid requirement compared to GA alone. In patients undergoing GA, the combination of a CPB with an ISB was associated with a small, although statistically significant, reduction in pain scores and opioid requirements compared to a CPB alone.

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 1—A Scoping Review

Objective. Clavicle fractures are common injuries potentially associated with significant perioperative pain. However, this region’s complex sensory innervation poses a challenge for regional anesthetic or analgesic (RA) techniques. We conducted this scoping review to summarize the current literature, particularly with regards to motor-sparing techniques. Methods. A scoping review was carried out in accordance with the Joanna Briggs Institute’s framework. All articles describing the use of RA for clavicle fractures or surgery were included. PubMed^®, Ovid MEDLINE^®, EMBASE^®, Scopus^®, CINAHL^®, and the Cochrane database were searched without language restrictions. Results. Database searches identified 845 articles, 44 of which were included in this review, with a combined patient total of 3161. We included all peer-reviewed publications containing clinical data and summarized the findings. Conclusions. Current evidence of RA techniques in clavicle surgery is heterogeneous, with different approaches used to overcome the overlapping sensory innervation. The literature largely comprises case reports/series, with several randomized controlled trials. Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block. Cervical plexus block can provide motor-sparing analgesia following clavicle surgery. Promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique. Further studies are required to determine the efficacy and safety of various techniques.

Evaluation of analgesic efficacy of superficial cervical plexus block in patients undergoing modified radical mastoidectomy: A randomised controlled trial

Background and Aims:

Intravenous analgesics and local infiltration are used for postoperative analgesia in patients undergoing mastoidectomy. No randomised controlled trial (RCT) has so far determined response rates of pain reduction after ultrasound-guided superficial cervical plexus block (SCPB) in adult patients undergoing modified radical mastoidectomy.

Methods:

This double-blind RCT was conducted in 30 adult patients of the American Society of Anesthesiologists (ASA) grade I/II undergoing modified radical mastoidectomy. The primary outcome was a reduction in the visual analogue scale (VAS) score. Secondary outcomes were postoperative diclofenac consumption, haemodynamics, and occurrence of any adverse events. All patients received general anaesthesia. At the end of the surgery, patients were randomised to either Group ‘Block’ (n = 15) ultrasound guided SCPB with 5 mL ropivacaine 0.5% or Group ‘No block’ (n = 15). All patients received intravenous (IV) paracetamol 1 g every 6 hourly and rescue analgesic IV diclofenac 75 mg if VAS score >4.

Results:

Patients in Group ‘Block’ reported lower VAS score at rest versus Group ‘No block’ at 1 h postoperatively (P = 0.012). VAS score on movement was lower in patients of Group ‘Block’ compared to Group ‘No block’ at 1 h (P = 0.010), 4 h (P = 0.035), 8 h (P = 0.027), and 12 h (*P = 0.003) postoperatively. Diclofenac consumption was lower in patients of Group ‘Block’ (P = 0.041). No adverse effects were reported.

Conclusion:

Postoperative ultrasound-guided SCPB produced higher response rates in terms of reduction in VAS score in patients undergoing modified radical mastoidectomy.

Ultrasound-guided supraclavicular nerve block for implantable port catheters: Does it show a significant difference in pain control?

BACKGROUND

Nerve blocks have been used for decades at head and neck region interventions and recently introduced as an alternative option for subcutaneous port implantation. This study aimed to compare two different local anesthesia techniques used during subcutaneous port implantation.

METHODS

This retrospective study was conducted with 107 patients who were categorized into two groups according to the local anesthesia techniques used during port implantations. Group 1 underwent local infiltration anesthesia and Group 2 received an ultrasound-guided supraclavicular nerve block. In both groups, prilocaine 2% was used for skin anesthesia and no other systemic anesthetic drugs or additional local anesthetics were administered during port implantation. Local anesthetic doses were 400 mg in Group 1 and 200 mg in Group 2. The time required for adequate cutaneous anesthesia, procedure time, complication rate and visual analog scale (VAS) score were recorded for each patient.

RESULTS

Groups 1 and 2 contained 58 and 49 patients respectively. Both groups showed similar demographic distributions of patients (p > 0.05). Mean procedure times and the time required for adequate cutaneous anesthesia were longer in Group 2 (p < 0.05). Group 2 also showed 12 immediate complications, although they were temporary and recovered without any intervention under surveillance. Mean VAS scores during port implantation were similar in both groups [Group 1: 1.17(±0.60), Group 2: 1.1(±0.62)] (p > 0.05).

CONCLUSIONS

The VAS scores did not differ significantly between groups. Although a supraclavicular nerve block may require lower local anesthetic doses for similar cutaneous anesthesia, it is associated with higher immediate complication rates due to unintended blockade of the peripheral nerves. Thus, if the nerve block is preferred over local infiltration anesthesia during port implantation, to prevent life-threatening complications, caution needed especially for the patients with contralateral vocal cord or diaphragm paralysis.

Ultrasound-guided superficial cervical plexus block for analgesia in patients undergoing craniotomy via suboccipital retrosigmoid approach: study protocol of a randomised controlled trial

INTRODUCTION

Scalp nerve block has been proven to be an alternative choice to opioids in multimodal analgesia. However, for the infratentorial space-occupying craniotomy, especially the suboccipital retrosigmoid craniotomy, scalp nerve block is insufficient.

METHODS AND ANALYSIS

The study is a prospective, single-centre, randomised, paralleled-group controlled trial. Patients scheduled to receive elective suboccipital retrosigmoid craniotomy will be randomly assigned to the superficial cervical plexus block group or the control group. After anaesthesia induction, superficial cervical plexus nerve block will be performed under the guidance of ultrasound. The primary outcome is the cumulative consumption of sufentanil by the patient-controlled intravenous analgesia pump within 24 hours after surgery. Secondary outcomes include the cumulative consumption of sufentanil at other four time points and numerical rating scale pain severity score.

ETHICS AND DISSEMINATION

The protocol (version number: 2.0, 10 April 2019) has been approved by the Ethics Review Committee of China Registered Clinical Trials (Ethics Review No. ChiECRCT-20190047). The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04036812.

Local Anesthesia for Port Catheter Placement in Oncology Patients: An Alternative to Landmark Technique Using Ultrasound-Guided Superficial Cervical Plexus Block-A Prospective Randomized Study

Background/Objectives

Most patients that require port operation have experienced severe pain due to multiple surgeries in the past. Therefore, these patients have fear of pain before the procedure. This study aims to compare superficial cervical plexus block (SCPB) with local infiltration anesthesia in terms of comfort.

Methods

100 cancer-diagnosed patients were divided into two groups. The first group, the landmark technique with local infiltration anesthesia, was used for intravenous entry (Group LM, n = 50). The second group, USG, was used for venous entry with SCPB as anesthesia (Group US, n = 50). The type of local anesthesia, port placement technique, duration of the procedure, number of procedures, complications, visual analog scale (VAS) score, and surgeon's satisfaction with the procedure were recorded.

Results

It was established that an average of 1.7 and 1.1 attempts was conducted in Groups LM and US, respectively (P = 0.010). VAS scores were found to be 4.04 in Group LM and 2.62 in GroupUS (P = 0.001). Surgeon satisfaction was 1.96 in GroupLM and 2.38 in GroupUS (P = 0.014). The mean duration of the procedure was 22.10 minutes in GroupLM and 43.50 minutes in GroupUS (P = 0.001). Complication rates were observed in 1 patient in GroupLM and 9 patient in GroupUS (P = 0.040).

Conclusions

In the patient group with a high level of pain and anxiety port catheter placement using USG and SCPB, supported by routine sedation, provides better comfort for both patient and surgeon.