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McLeod G, Reina MA. Nerve block, nerve damage, and fluid injection pressure: overturning the myth. Br J Anaesth 2024; 132:1022-1026. [PMID: 38182528 DOI: 10.1016/j.bja.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 01/07/2024] Open
Abstract
Histological and micro-ultrasound evidence rebuffs deep-rooted views on the nature of nerve block, nerve damage, and injection pressure monitoring. We propose that the ideal position of the needle tip for nerve block is between the innermost circumneural fascial layer and outer epineurium, with local anaesthetic passing circumferentially through adipose tissue. Thin, circumferential, subepineural expansion that is invisible to the naked eye was identified using micro-ultrasound, and could account for variability of outcomes in clinical practice. Pressure monitoring cannot differentiate between intrafascicular and extrafascicular injection. High injection pressure only indicates intraneural extrafascicular spread, not intrafascicular spread, because it is not possible to inject into the stiff endoneurium in most human nerves.
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Affiliation(s)
- Graeme McLeod
- NHS Tayside, Ninewells Hospital, Dundee, UK; Imaging & Technology, University of Dundee, Dundee, UK; Engineering & Physical Sciences, Heriot-Watt University, Edinburgh, UK.
| | - Miguel A Reina
- CEU San Pablo University Faculty of Medicine, Madrid, Spain; Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain; University of Florida, College of Medicine, Gainesville, FL, USA
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2
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Lemke E, Johnston DF, Behrens MB, Seering MS, McConnell BM, Swaran Singh TS, Sondekoppam RV. Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance. Reg Anesth Pain Med 2024; 49:122-132. [PMID: 37940348 DOI: 10.1136/rapm-2023-104855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed. OBJECTIVE In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance. EVIDENCE REVIEW A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion. FINDINGS The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block. CONCLUSIONS Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.
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Affiliation(s)
- Ethan Lemke
- Emergency Medicine, University of Michigan Health-West, Wyoming, Michigan, USA
| | - David F Johnston
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Matthew B Behrens
- Department of Emergency Medicine, Kent Hospital, Warwick, Rhode Island, USA
| | - Melinda S Seering
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
| | - Brie M McConnell
- Davis Library, University of Waterloo, Waterloo, Ontario, Canada
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Eby SF, Teramoto M, Lider J, Lash M, Caragea M, Cushman DM. Sonographic peripheral nerve cross-sectional area in adults, excluding median and ulnar nerves: A systematic review and meta-analysis. Muscle Nerve 2023; 68:20-28. [PMID: 36583383 DOI: 10.1002/mus.27783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION/AIMS Although electromyography remains the "gold standard" for assessing and diagnosing peripheral nerve disorders, ultrasound has emerged as a useful adjunct, providing valuable anatomic information. The objective of this study was to conduct a systematic review and meta-analysis evaluating the normative sonographic values for adult peripheral nerve cross-sectional area (CSA). METHODS Medline and Cochrane Library databases were systematically searched for healthy adult peripheral nerve CSA, excluding the median and ulnar nerves. Data were meta-analyzed, using a random-effects model, to calculate the mean nerve CSA and its 95% confidence interval (CI) for each nerve at a specific anatomical location (= group). RESULTS Thirty groups were identified and meta-analyzed, which comprised 16 from the upper extremity and 15 from the lower extremity. The tibial nerve (n = 2916 nerves) was reported most commonly, followed by the common fibular nerve (n = 2580 nerves) and the radial nerve (n = 2326 nerves). Means and 95% confidence interval (CIs) of nerve CSA for the largest number of combined nerves were: radial nerve assessed at the spiral groove (n = 1810; mean, 5.14 mm2 ; 95% CI, 4.33 to 5.96); common fibular nerve assessed at the fibular head (n = 1460; mean, 10.18 mm2 ; 95% CI, 8.91 to 11.45); and common fibular nerve assessed at the popliteal fossa (n = 1120; mean, 12.90 mm2 ; 95% CI, 9.12 to 16.68). Publication bias was suspected, but its influence on the results was minimal. DISCUSSION Two hundred thirty mean CSAs from 15 857 adult nerves are included in the meta-analysis. These are further categorized into 30 groups, based on anatomical location, providing a comprehensive reference for the clinician and researcher investigating adult peripheral nerve anatomy.
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Affiliation(s)
- Sarah F Eby
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joshua Lider
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Madison Lash
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Sonawane K, Dixit H, Thota N, Jayaraj A, Balavenkatasubramanian J. "Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part D (Approach to the Patient With Nerve Injuries). Cureus 2023; 15:e41782. [PMID: 37575754 PMCID: PMC10419331 DOI: 10.7759/cureus.41782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
"Prevention is always better than cure." However, despite all precautions or preventive measures, sometimes patients develop neurodeficits due to suspected nerve injury in the perioperative period. Assessment and evaluation of the patient's symptoms can provide clues to the causative factors. Such causative factors can be corrected immediately to avoid further deterioration, or some may require further workup. The management plan for such a diagnosed nerve injury depends on the symptoms, the finding of the medical history, and the diagnostic imaging and tests. Simultaneous symptomatic relief in the form of pain medications, steroids, anti-inflammatory drugs, psychological counseling, and reassurance is essential to expedite treatment goals. Diagnosing and treating nerve injuries cannot be laid down as a straightforward part. It is a zigzag puzzle in its own right, playing with time and injury progression. Careful assessment to diagnose the extent of nerve damage plays an important role in treatment plans. It helps decide when to proceed and when to postpone, whether conservative strategies would suffice, or surgical repair would be required. Although most nerve injuries are self-limiting, some cases require surgical intervention that needs to be diagnosed early. The revolution was started by Sunderland in 1945 when he described neurosurgical techniques that drastically changed the entire scenario of nerve repairs. The ultimate effective treatment and full recovery may not be guaranteed, but attempts must be made to achieve the best results. With the patient's interests in mind, it is important to formulate a plan ensuring a good quality of life with minimal impact on their daily activities. Multifactorial nerve injury requires a multidisciplinary approach that primarily includes reassuring, psychological counseling, multimodal analgesia, and neurological and occupational consultations. This article describes the step-by-step approach known as the symptoms categorization-history taking-examination-diagnostic evaluations (SHED) approach to managing patients with peripheral nerve injuries. It also details the various modalities for diagnosing nerve injuries, sequential electrodiagnostic studies, and treatment plans depending on the type and extent of nerve injuries. It will help readers to design a treatment plan based on the patient's symptoms and evaluation results.
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Affiliation(s)
- Kartik Sonawane
- Anesthesiology, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, IND
| | - Hrudini Dixit
- Anesthesiology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, IND
| | - Navya Thota
- Anesthesiology, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, IND
| | - Aparna Jayaraj
- Anesthesiology, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, IND
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Diwan S, Areti A, Sivashanmugam T, Sancheti P. Neurovascular complications related to nerve stimulator-guided lumbosacral plexus block for proximal femur nailing in geriatric patients-A retrospective study. Indian J Anaesth 2022; 66:800-803. [PMID: 36590186 PMCID: PMC9795506 DOI: 10.4103/ija.ija_462_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sandeep Diwan
- Department of Anaesthesiology, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India
| | - Archana Areti
- Department of Anaesthesiology, Mahatma Gandhi and Research Institute, Sri Balaji Vidyapeeth Deemed to be University, Puducherry, India,Address for correspondence: Dr. Archana Areti, Department of Anaesthesiology, Mahatma Gandhi and Research Institute, Sri Balaji Vidyapeeth Deemed to be University, Pillaiyarkuppam, Puducherry - 607402, India. E-mail:
| | - T Sivashanmugam
- Department of Anaesthesiology, Mahatma Gandhi and Research Institute, Sri Balaji Vidyapeeth Deemed to be University, Puducherry, India
| | - Parag Sancheti
- Department of Orthopaedic Surgery, Sancheti Hospital for Orthopaedics and Rehabilitation, Pune, Maharashtra, India
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McLeod GA, Sadler A, Hales TG. Traumatic needle damage to nerves during regional anesthesia: presentation of a novel mechanotransduction hypothesis. Reg Anesth Pain Med 2022; 47:rapm-2022-103583. [PMID: 35878962 DOI: 10.1136/rapm-2022-103583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022]
Abstract
Despite advances in needle positioning techniques, nerve damage still occurs after regional anesthesia. Recognized causes include local anesthetic toxicity, subperineural injection, high subepineural fluid injection pressures and subepineural hematoma after forceful needle--nerve contact.We hypothesize that subperineural injection is still possible, but less likely to be the cause of nerve damage because needle penetration of fascicles and mechanical damage is difficult to achieve. High-resolution (75 µm) 40 MHz micro-ultrasound images of pig axillae show short-bevelled 22 g, 0.7 mm wide block needles that are three times larger than the average fascicle. Fascicular bundles are extremely difficult to puncture because they spin away on needle contact. Histology from fresh cadavers after supposed intrafascicular injection shows fluid spread within perineurium and intrafascicular perineural septae, but no breach of endoneurium or axons.We propose that mechanotransduction, the cellular changes that occur in response to force, contributes to nerve damage. Piezo ion channel proteins transduce force into electrical activity by rapid entry of cations into cells. Excessive Ca2+ influx into cells has the potential to inhibit nerve regeneration. Cellular changes include regulation of gene expression. The forces associated with purposeful needle insertion are generally unknown. Our experiments in the soft embalmed Thiel cadaver showed a lognormal range of forces between 0.6 N and 16.8 N on epineural penetration.We hypothesize that forceful needle injury may cause nerve damage by activation of Piezo receptors and release of intracellular Ca2.
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Affiliation(s)
- Graeme A McLeod
- Department of Anaesthesia, NHS Tayside, Dundee, UK
- Division of Imaging and Technology, University of Dundee, Dundee, UK
| | - Amy Sadler
- Department of Anaesthesia, NHS Tayside, Dundee, UK
| | - Tim G Hales
- Division of Systems Medicine, University of Dundee, Dundee, UK
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7
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Chandra A, Soenjaya Y, Yan J, Felts P, McLeod G, Demore C. Real-time visualisation of peripheral nerve trauma during subepineural injection in pig brachial plexus using micro-ultrasound. Br J Anaesth 2021; 127:153-163. [PMID: 34006377 DOI: 10.1016/j.bja.2021.03.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Nerve damage is consistently demonstrated after subepineural injection in animal studies, but not after purposeful injection in patients participating in clinical studies. There is a need to better visualise nerves in order to understand the structural changes that occur during subepineural injection. METHODS We scanned the brachial plexuses of three anaesthetised pigs using micro-ultrasound imaging (55-22 MHz probe), inserted 21 gauge block needles into the radial, median, and axillary nerves, and injected two 0.5 ml boluses of saline into nerves at a rate of 12 ml min-1. Our objectives were to measure the area and diameter of nerves and fascicles, and to describe changes in nerve anatomy, comparing our findings with histology. RESULTS Images were acquired at 42 sites across 18 nerves in three pigs and compared dimensions (geometric ratio; 95% confidence interval; P value). As expected, the nerve cross-sectional area was greater in the proximal brachial plexus compared with the mid-plexus (2.10; 1.07-4.11; P<0.001) and the distal plexus (2.64; 1.42-4.87; P<0.001). Nerve area expanded after 0.5 ml injection (2.13; 1.48-3.08; P<0.001). Using microultrasound, subepineural injection was characterised by nerve and fascicle rotation, uniform, or localised swelling and epineural rupture. Micro-ultrasound revealed a unique pattern suggestive of subperineural injection after a median nerve injection, and good face validity with histology. Histology showed epineural trauma and inflammation to the perineurium. CONCLUSION We accurately identified fascicles and real-time structural changes to peripheral nerves using micro-ultrasound. This is the first study to visualise in vivo and in real-time the motion of nerves and fascicles in response to anaesthetic needle insertion and fluid injection.
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Affiliation(s)
- Anu Chandra
- School of Medicine, University of Dundee, Ninewells Hospital, Dundee, UK
| | | | - Judy Yan
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Paul Felts
- Centre for Anatomy and Human Identification, University of Dundee, Dundee, UK
| | - Graeme McLeod
- Institute of Academic Anaesthesia, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, UK.
| | - Christine Demore
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Medical BioPhysics, University of Toronto, Toronto, Canada
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8
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Karmakar MK, Reina MA, Sivakumar RK, Areeruk P, Pakpirom J, Sala-Blanch X. Ultrasound-guided subparaneural popliteal sciatic nerve block: there is more to it than meets the eyes. Reg Anesth Pain Med 2020; 46:268-275. [PMID: 33077429 DOI: 10.1136/rapm-2020-101709] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022]
Abstract
The popliteal sciatic nerve block is routinely used for anesthesia and analgesia during foot and ankle surgery. This article reviews our current understanding of the anatomy of the sciatic nerve and discusses how fascial tissue layers associated with the nerve may affect block outcomes . The anatomy of the sciatic nerve is more complex than previously described. The tibial and common peroneal nerves within the sciatic nerve trunk appear to be centrally separated by the Compton-Cruveilhier septum and encompassed by their own paraneural sheaths. This unique internal architecture of the sciatic nerve appears to promote proximal spread of local anesthetic to the internal aspect of the sciatic nerve trunk after a subparaneural injection at or below the divergence of the tibial and common peroneal nerves.
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Affiliation(s)
- Manoj Kumar Karmakar
- Department of Anesthesia and Intensice Care, The Chinese University of Hong Kong Faculty of Medicine, Shatin, New Territories, Hong Kong, China
| | - Miguel A Reina
- Department of Anesthesiology, CEU San Pablo University School of Medicine, Madrid, Spain
| | - Ranjith Kumar Sivakumar
- Department of Anesthesia and Intensice Care, The Chinese University of Hong Kong Faculty of Medicine, Shatin, New Territories, Hong Kong, China
| | - Pornpatra Areeruk
- Department of Anesthesia and Intensice Care, The Chinese University of Hong Kong Faculty of Medicine, Shatin, New Territories, Hong Kong, China
| | - Jatuporn Pakpirom
- Department of Anesthesia and Intensice Care, The Chinese University of Hong Kong Faculty of Medicine, Shatin, New Territories, Hong Kong, China
| | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain.,Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
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Laredo FG, Belda E, Soler M, Gil F, Murciano J, Sánchez-Campillo J, Agut A. Short-Term Effects of Deliberate Subparaneural or Subepineural Injections With Saline Solution or Bupivacaine 0.75% in the Sciatic Nerve of Rabbits. Front Vet Sci 2020; 7:217. [PMID: 32478104 PMCID: PMC7235316 DOI: 10.3389/fvets.2020.00217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasound (US)-guided techniques for peripheral nerve blockade have revealed that intraneural injections are relatively frequent and not necessarily associated with neurological deficits. Objectives: To evaluate the short-term effects of deliberate injections performed under direct vision in two different sites of the sciatic nerve (ScN). Material and Methods: Seventy-two New Zealand white rabbits randomly assigned to one of four experimental groups (n = 18) were employed. All procedures were conducted at a proximal femoral level where the ScN incorporates the common peroneal nerve and the tibial nerve (TN). Fixed volumes of 0.5 ml of saline solution (ES group) or bupivacaine 0.75% (EB group) were administered extrafascicularly inside the paraneurium of the ScN or intrafascicularly (IS and IB groups) under the epineurium of the TN. Cross-sectional area (CSA) and relative echogenicity (RE) of the entire ScN were determined by US before injections, after injections, and at 3 and 7 days. ScN samples were obtained for structural and ultrastructural histopathological studies. Proprioceptive, sensorial, and motor function were clinically evaluated on a daily basis. Results: The CSA of the ScN increased significantly immediately after injections when compared with pre-injection values in all groups (p < 0.05). The RE of the ScN decreased in relation to pre-injection values in all groups (p < 0.05). The CSA and RE of the ScN returned to normal values 7 days after injections in almost all groups. Injected nerves showed histological signs of mild perineural inflammation. Histopathological scores were not significantly different between groups (p > 0.05). The architecture of the ScN was preserved in all rabbits at 3 days and in 31/32 rabbits at 7 days. A focal area of damaged nerve fibers with degeneration of the axons and myelin sheath affecting the TN was observed in one rabbit of the IB group. Nerve function was not clinically impaired in any case. Conclusion: Despite the lack of severe nerve disruption observed in most rabbits, the evidence of a focal area of damaged nerve fibers in one rabbit injected intrafascicularly with bupivacaine confirms that intrafascicular injections should be avoided as they may increase the risk of nerve damage.
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Affiliation(s)
- Francisco G Laredo
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Eliseo Belda
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Marta Soler
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Francisco Gil
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - José Murciano
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Joaquín Sánchez-Campillo
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Amalia Agut
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
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Dieguez-Garcia P, Lopez-Alvarez S, Juncal J, Lopez AM, Sala-Blanch X. Comparison of the effectiveness of circumferential versus non-circumferential spread in median and ulnar nerve blocks. A double-blind randomized clinical trial. Reg Anesth Pain Med 2020; 45:362-366. [PMID: 32165554 DOI: 10.1136/rapm-2019-101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Circumferential (C) spread of local anesthetic around the nerve is recommended for a successful nerve block. We tested the hypothesis that C spread produces a more complete block than non-circumferential (NC) spread. METHODS We randomized 124 patients undergoing open carpal tunnel syndrome surgery to receive C or NC spread ultrasound-guided median and ulnar nerve blocks. The primary outcome was the proportion of patients who developed complete sensory block measured at 5, 15 and 30 min. The loss of cold sensation was graded as: 0 (complete block), 1 (incomplete block), or 2 (no block). Secondary outcomes included motor block, nerve swelling and adverse events. RESULTS In group C, complete sensory block at 5 min was 2.4 (95% CI 1.0 to 5.7; p=0.04) times more frequent in the median nerve and 3.0 (95% CI 1.2 to 7.2; p=0.01) times more frequent in the ulnar nerve compared with group C. However, at 15 and 30 min, it was similar between groups. Complete motor block was more frequent in group C than in group NC for both the median nerve: 1.5 (95% CI 1.1 to 2.2; p<0.01) at 15 min, 1.1 (95% CI 1.0 to 1.2; p=0.02) at 30 min, and the ulnar nerve: 1.7 (95% CI 1.2 to 2.6; p<0.01) at 15 min, 1.2 (95% CI 1.0 to 1.4; p<0.01) at 30 min. The incidence of nerve swelling and adverse effects was similar between groups. CONCLUSIONS C spread around the median and ulnar nerves at the level of the antecubital fossa generates more complete sensory and motor blocks compared with NC spread. TRIAL REGISTRATION NUMBER EudraCT 2011-002608-34 and NCT01603680.
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Affiliation(s)
| | | | - Jorge Juncal
- Anesthesiology, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Ana M Lopez
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Catalonia, Spain
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Dmytriiev D, Lysak Y, Glazov Y, Geranin S, Zaletska O. Mini-invasive methods of treatment of diabetic foot pain. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v4i3.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Neuropathic pain occurs with diabetic polyneuropathy more often than with all polyneuropathies of another etiology. Because the cause of pain can rarely be cured, treatment is usually symptomatic. Neuropathic pain is usually poorly controlled by analgesics. Management of neuropathic pain is started with conservative pharmacotherapy before invasive pain management is applied. Although there are many drugs that can be used in patients with diabetic pain syndrome, pain syndrome can not be surely stoped with monotherapy. In addition, the patient may not tolerate the full therapeutic dose of the drug.
All this dictates the need for combination therapy. It is believed that regional anesthesia as an independent type of analgesia or a component of combined anesthesia is the method of choice for the elderly and senile patients. The main reasons for this choice, when comparing regional anesthesia with narcosis, are less stressful response of the organism, absence of depression of the central nervous system, stable reliable analgesia with complete blockade of nociceptive reflexes with the provision of adequate muscle relaxation, prevention of neurovegetative reactions, which ultimately helps to reduce the incidence of postoperative complications and mortality. Clinicians have accumulated considerable experience demonstrating the need for regional analgesia in the management of diabetic foot pain.
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12
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Schütz M, Hopf HB, Magunia J. [Blockade of the distal sciatic nerve in the supine position with a newly developed ultrasound probe holder]. Anaesthesist 2019; 68:615-617. [PMID: 31463544 DOI: 10.1007/s00101-019-00653-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sonographically controlled blockade of the distal sciatic nerve is usually performed by placing the ultrasound probe on the dorsal side of the thigh. This requires positioning maneuvers (prone or side positioning) of the patient as well as additional assistance. In order to avoid these positioning maneuvers, a positioning aid with integrated ultrasound probe holder has been developed and its practicability was examined on patients with lower limb surgery. The sonographically controlled block of the sciatic nerve was performed with the patient under general anesthesia and in a supine position with the help of the new positioning aid with an integrated ultrasound probe holder. A total of >100 patients were treated, who underwent elective lower leg, ankle or foot surgery with a continuous blockade of the distal sciatic nerve using catheters for postoperative analgesia. The advantages are easy performance, hands-free needle movement and catheter placement. The disadvantages might be the need for in-plane catheter placement and a fixed ultrasound angle.
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Affiliation(s)
- M Schütz
- Anästhesie und Intensivmedizin, Asklepios Klinik im Städtedreieck, Dr. Sauerbruch Straße 1, 93133, Burglengenfeld, Deutschland.
| | - H B Hopf
- Abteilung für Anästhesie und Perioperative Medizin, Asklepios Klinik Langen, Röntgenstraße 20, 63225, Langen, Deutschland
| | - J Magunia
- Abteilung für Anästhesie und Perioperative Medizin, Asklepios Klinik Langen, Röntgenstraße 20, 63225, Langen, Deutschland
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Büttner B, Schwarz A, Mewes C, Kristof K, Hinz J, Quintel M, Mansur A, Bergmann I. Subparaneural Injection in Popliteal Sciatic Nerve Blocks Evaluated by MRI. Open Med (Wars) 2019; 14:346-353. [PMID: 31157299 PMCID: PMC6534099 DOI: 10.1515/med-2019-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 03/25/2019] [Indexed: 11/30/2022] Open
Abstract
Intraneural injection of a local anesthetic can damage the nerve, yet it occurs frequently during distal sciatic block with no neurological sequelae. This has led to a controversy about the optimal needle tip placement that results from the particular anatomy of the sciatic nerve with its paraneural sheath. The study population included patients undergoing lower extremity surgery under popliteal sciatic nerve block. Ultrasound-guidance was used to position the needle tip subparaneurally and to monitor the injection of the local anesthetic. Sonography and magnetic resonance imaging were used to assess the extent of the subparaneural injection. Twenty-two patients participated. The median sciatic cross-sectional area increased from 57.8 mm2 pre-block to 110.8 mm2 immediately post-block. An intraneural injection according to the current definition was seen in 21 patients. Two patients had sonographic evidence of an intrafascicular injection, which was confirmed by MRI in one patient (the other patient refused further examinations). No patient reported any neurological symptoms. A subparaneural injection in the popliteal segment of the distal sciatic nerve is actually rarely intraneural, i.e. intrafascicular. This may explain the discrepancy between the conventional sonographic evidence of an intraneural injection and the lack of neurological sequelae.
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Affiliation(s)
- Benedikt Büttner
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Alexander Schwarz
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen Germany
| | - Caspar Mewes
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Katalin Kristof
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - José Hinz
- Department of Anesthesiology, Emergency and Intensive Care Medicine, Klinikum Region Hannover, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Ashham Mansur
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
| | - Ingo Bergmann
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Goettingen, Robert-Koch Str. 40, 37075 Goettingen, Germany
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Silva Herrera RE, Serrá Sandoval A, Gonzalez Venegas M, de Lara González S, Gracia J, Sala-Blanch X. Cross-sectional area of the median nerve after intraneural vs perineural low volume administration. ACTA ACUST UNITED AC 2018; 66:122-128. [PMID: 30528459 DOI: 10.1016/j.redar.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1ml of solution. MATERIAL AND METHODS Ultrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions (3 per forearm). They were randomised into the intraneural (n=30) or perineural (n=30) location of the needle tip, after the consensus of location by 7 specialists. After 1ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve, as well as the displacement along the nerve. RESULTS The cross-sectional area of the median nerve was increased in both groups, however, the increase was significantly higher in the intraneural group (perineural 0.007±0.013cm2 vs. intraneural 0.032±0.021cm2, P<.0001). An increase of more than 27% of the area ensures an intraneural injection in the median nerve according to the ROC curve analysis. Both proximal and distal diffusion were observed more frequently in the intraneural group (proximal: 86% vs 14%, P<.0001, Distal: 43% vs 4%, P<.0001). CONCLUSIONS Based on this experimental study, it is concluded that the injection of a small volume (1ml) allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases. Therefore, it is suggested that this "dose test" should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection.
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Affiliation(s)
| | - A Serrá Sandoval
- Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | | | | | - J Gracia
- Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - X Sala-Blanch
- Facultad de Medicina, Universitat de Barcelona, Barcelona, España; Hospital Clinic, Universitat de Barcelona, Barcelona, España.
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15
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Regional anesthetic techniques for the thoracic limb and thorax in small animals: A review of the literature and technique description. Vet J 2018; 241:8-19. [DOI: 10.1016/j.tvjl.2018.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 12/17/2022]
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16
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Sermeus LA, Vanlinthout LE, Hans GH, Schepens T, Breebaart MB, Verheyen VC, Smitz CJ, Vercauteren MP. Effects of Stellate Ganglion Block on Analgesia Produced by Cervical Paravertebral Block as Established by Quantitative Sensory Testing: A Randomized Controlled Trial. PAIN MEDICINE 2018; 19:2223-2235. [PMID: 29408967 DOI: 10.1093/pm/pny004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To use quantitative sensory testing (QST) to assess whether a stellate ganglion block (SGB) modulates the analgesia induced by cervical paravertebral block (CPVB). Design A prospective double-blind randomized controlled trial. Setting Department of Anesthesia, Antwerp University Hospital, October 2011 to December 2015. Subjects Twenty-eight adults scheduled for arthroscopy of a nonfractured shoulder were enrolled. Methods Participants were randomly assigned to receive either single CPVB (5 mL of levobupivacaine 0.5%) or combined CPVB + SGB (5 mL and 3 mL of levobubivacaine 0.5%, respectively). The detection thresholds for cold/warm sensations and cold/heat pain were established using thermal QST on the C4-C7 dermatomes before local anesthetic infiltration and at 0.5, 6, 10, and 24 hours thereafter. Our primary outcome was the time course of QST thresholds for the different neurosensitive/nociceptive modalities. As secondary and tertiary outcomes, we evaluated the degree of motor block and the time to first administration of rescue analgesics. Results We randomized 20 patients. There were no significant differences in the detection thresholds for the neurosensitive/nociceptive modalities, motor block, or timing for rescue analgesics between the groups (P = 0.15-0.94). All patients with CPVB + SGB exhibited Horner's signs, whereas patients in the CPVB group did not exhibit these signs; however, this does not exclude sympathetic block. Conclusions We were unable to demonstrate any analgesic benefit of CPVB + SGB in arthroscopic shoulder surgery. It is therefore not unreasonable to suppose that pain from soft tissue injuries without bony lesions is transmitted mainly by somatic nerves with no or only minimal involvement of the sympathetic nervous system.
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Affiliation(s)
- Luc A Sermeus
- Department of Anesthesia, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Luc E Vanlinthout
- Department of Anesthesiology, University Hospital Gasthuisberg, Leuven, Belgium.,Interuniversity Institute for Biostatistics and Department of Mathematics & Statistics, Statistical Bioinformatics, Universities of Leuven and Hasselt, Leuven and Diepenbeek, Belgium
| | - Guy H Hans
- Department of Algology and Evidence Based Medicine, Multidisciplinary Pain Center, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Tom Schepens
- Department of Anesthesiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Margaretha B Breebaart
- Department of Anesthesia, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Veerle C Verheyen
- Department of Anesthesiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Carine J Smitz
- Department of Anesthesiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Marcel P Vercauteren
- Department of Anesthesiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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18
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Portela DA, Verdier N, Otero PE. Regional anesthetic techniques for the pelvic limb and abdominal wall in small animals: A review of the literature and technique description. Vet J 2018; 238:27-40. [PMID: 30103913 DOI: 10.1016/j.tvjl.2018.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 06/24/2018] [Accepted: 07/13/2018] [Indexed: 11/17/2022]
Abstract
Increasing interest in using peripheral nerve blocks in small animals is evident, given the numerous studies published recently on this topic in important veterinary journals. Initially, research was focused on intraoperative analgesia to the pelvic limb, and several descriptions of lumbosacral plexus, femoral and sciatic nerve blocks have been described in studies. There is recent interest in developing techniques for somatosensory blockade of the abdominal wall. This article is the second part of a two-part review of regional anesthesia (RA) in small animals, and its aim is to discuss the most relevant studies in the veterinary literature, where objective methods of nerve location have been used, and to illustrate in pictures the currently used techniques for providing RA to the abdominal wall and the pelvic limb in small animals.
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Affiliation(s)
- D A Portela
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA.
| | - N Verdier
- Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Buenos Aires, Argentina
| | - P E Otero
- Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Buenos Aires, Argentina
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Krol A, Vala A, Phylactides L, Szarko M, Reina MA, De Andres J. Injection pressure mapping of intraneural vs. perineural injections: further lessons from cadaveric studies. Minerva Anestesiol 2018; 84:907-918. [DOI: 10.23736/s0375-9393.18.12230-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Rodríguez Prieto M, González FJ, Sabaté S, García M, Lamas C, Font A, Moreno M, Proubasta I, Gil De Bernabé MÀ, Moral MV, Hoffmann R. Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: a randomized controlled trial. Minerva Anestesiol 2018; 84:1261-1269. [PMID: 29405670 DOI: 10.23736/s0375-9393.18.12291-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia. METHODS Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mL on radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block. RESULTS Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV). CONCLUSIONS dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.
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Affiliation(s)
| | - F Javier González
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sergi Sabaté
- Department of Anesthesiology, Puigvert Foundation, Barcelona, Spain
| | - Mercedes García
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Claudia Lamas
- Department of Orthopedic and Hand Surgery, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Adrià Font
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marisa Moreno
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ignasi Proubasta
- Department of Orthopedic and Hand Surgery, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - M Victoria Moral
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Rolf Hoffmann
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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21
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Sondekoppam RV, Tsui BCH. Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks. Anesth Analg 2017; 124:645-660. [DOI: 10.1213/ane.0000000000001804] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Munirama S, Zealley K, Schwab A, Columb M, Corner G, Eisma R, McLeod G. Trainee anaesthetist diagnosis of intraneural injection—a study comparing B-mode ultrasound with the fusion of B-mode and elastography in the soft embalmed Thiel cadaver model. Br J Anaesth 2016; 117:792-800. [DOI: 10.1093/bja/aew337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/13/2022] Open
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23
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Comparison of histopathological effects of perineural administration of bupivacaine and bupivacaine-dexmedetomidine in rat sciatic nerve. ACTA ACUST UNITED AC 2016; 68:559-564. [DOI: 10.1016/j.etp.2016.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/05/2016] [Accepted: 09/07/2016] [Indexed: 11/19/2022]
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24
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Heschl S, Hallmann B, Zilke T, Gemes G, Schoerghuber M, Auer-Grumbach M, Quehenberger F, Lirk P, Hogan Q, Rigaud M. Diabetic neuropathy increases stimulation threshold during popliteal sciatic nerve block. Br J Anaesth 2016; 116:538-45. [PMID: 26994231 PMCID: PMC4797685 DOI: 10.1093/bja/aew027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Peripheral nerve stimulation is commonly used for nerve localization in regional anaesthesia, but recommended stimulation currents of 0.3-0.5 mA do not reliably produce motor activity in the absence of intraneural needle placement. As this may be particularly true in patients with diabetic neuropathy, we examined the stimulation threshold in patients with and without diabetes. METHODS Preoperative evaluation included a neurological exam and electroneurography. During ultrasound-guided popliteal sciatic nerve block, we measured the current required to produce motor activity for the tibial and common peroneal nerve in diabetic and non-diabetic patients. Proximity to the nerve was evaluated post-hoc using ultrasound imaging. RESULTS Average stimulation currents did not differ between diabetic (n=55) and non-diabetic patients (n=52). Although the planned number of patients was not reached, the power goal for the mean stimulation current was met. Subjects with diminished pressure perception showed increased thresholds for the common peroneal nerve (median 1.30 vs. 0.57 mA in subjects with normal perception, P=0.042), as did subjects with decreased pain sensation (1.60 vs. 0.50 mA in subjects with normal sensation, P=0.038). Slowed ulnar nerve conduction velocity predicted elevated mean stimulation current (r=-0.35, P=0.002). Finally, 15 diabetic patients required more than 0.5 mA to evoke a motor response, despite intraneural needle placement (n=4), or required currents ≥2 mA despite needle-nerve contact, vs three such patients (1 intraneural, 2 with ≥2 mA) among non-diabetic patients (P=0.003). CONCLUSIONS These findings suggest that stimulation thresholds of 0.3-0.5 mA may not reliably determine close needle-nerve contact during popliteal sciatic nerve block, particularly in patients with diabetic neuropathy. CLINICAL TRIAL REGISTRATION NCT01488474.
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Affiliation(s)
- S Heschl
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
| | - B Hallmann
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
| | - T Zilke
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
| | - G Gemes
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
| | - M Schoerghuber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
| | - M Auer-Grumbach
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz 8036, Austria
| | - F Quehenberger
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Auenbruggerplatz 2, Graz 8036, Austria
| | - P Lirk
- Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
| | - Q Hogan
- Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - M Rigaud
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29/I, Graz 8036, Austria
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Krol A, De Andres J. Plexus and peripheral nerve block anaesthesia--a step beyond ultrasound or full circle? ACTA ACUST UNITED AC 2016; 63:129-34. [PMID: 26782289 DOI: 10.1016/j.redar.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022]
Affiliation(s)
- A Krol
- Department of Anaesthesia and Chronic Pain Service, St Georges University Hospitals, London, UK.
| | - J De Andres
- Department of Anaesthesia, Critical Care and Pain Management, University of Valencia, School of Medicine, General University Hospital, Valencia, Spain
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The Requisites of Needle-to-Nerve Proximity for Ultrasound-Guided Regional Anesthesia. Reg Anesth Pain Med 2016; 41:221-8. [DOI: 10.1097/aap.0000000000000201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brull R, Hadzic A, Reina MA, Barrington MJ. Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade. Reg Anesth Pain Med 2015; 40:479-90. [PMID: 25974275 DOI: 10.1097/aap.0000000000000125] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review synthesizes anatomical, anesthetic, surgical, and patient factors that may contribute to neurologic complications associated with peripheral nerve blockade. Peripheral nerves have anatomical features unique to a given location that may influence risk of injury. Peripheral nerve blockade-related peripheral nerve injury (PNI) is most severe with intrafascicular injection. Surgery and its associated requirements such as positioning and tourniquet have specific risks. Patients with preexisting neuropathy may be at an increased risk of postoperative neurologic dysfunction. Distinguishing potential causes of PNI require clinical assessment and investigation; a definitive diagnosis, however, is not always possible. Fortunately, most postoperative neurologic dysfunction appears to resolve with time, and the incidence of serious long-term nerve injury directly attributable to peripheral nerve blockade is relatively uncommon. Nonetheless, despite the use of ultrasound guidance, the risk of block-related PNI remains unchanged. WHAT'S NEW Since the 2008 Practice Advisory, new information has been published, furthering our understanding of the microanatomy of peripheral nerves, mechanisms of peripheral nerve injection injury, toxicity of local anesthetics, the etiology of and monitoring methods, and technologies that may decrease the risk of nerve block-related peripheral nerve injury.
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Affiliation(s)
- Richard Brull
- From the *Departments of Anesthesia, Toronto Western Hospital, University Health Network, and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, St Luke's and Roosevelt Hospitals, New York, NY; ‡School of Medicine, CEU San Pablo University, and Madrid Montepríncipe University Hospital, Madrid, Spain; and §Department of Anaesthesia, St Vincent's Hospital; Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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An improvised pressure gauge for regional nerve blockade/anesthesia injections: an initial study. J Clin Monit Comput 2015; 29:673-9. [DOI: 10.1007/s10877-015-9701-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
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29
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The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2015; 40:401-30. [DOI: 10.1097/aap.0000000000000286] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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30
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Patil JJ, Ford S, Egeler C, Williams DJ. The effect of needle dimensions and infusion rates on injection pressures in regional anaesthesia needles: a bench-top study. Anaesthesia 2014; 70:183-9. [PMID: 25290190 DOI: 10.1111/anae.12869] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 11/27/2022]
Abstract
Animal studies have shown that injection pressures > 75 kPa indicate probable intrafascicular needle tip position. This study describes the flow/pressure characteristics of seven common needle systems. A syringe pump delivered flow rates of 5, 6.67, 10, 13.3, 15 and 20 ml.min(-1) through these needle systems, while keeping the needle tips open to atmosphere. A pressure transducer connected between the syringe and needle provided a real-time graphical display for analysis. Mean plateau pressures increased linearly with flow and with decreasing needle diameter (2.7-92 kPa). Flow rates > 17 ml.min(-1) and needle sizes 22 G and smaller produced mean plateau pressures > 75 kPa. Pressure monitors upstream from the needle may produce false-positive alarms at high flow rates due to needle resistance, and unreliable readings due to non-laminar flow. We recommend injection rates ≤ 15 ml.min(-1) (0.25 ml.s(-1) ) to reduce the effect of factors upstream from the needle tip as a cause of high pressure readings.
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Affiliation(s)
- J J Patil
- Department of Anaesthesia and Intensive Care, Airedale General Hospital, Steeton, UK
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Intraneural or extraneural: diagnostic accuracy of ultrasound assessment for localizing low-volume injection. Reg Anesth Pain Med 2014; 39:409-13. [PMID: 25068413 DOI: 10.1097/aap.0000000000000124] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES When one is performing ultrasound-guided peripheral nerve blocks, it is common to inject a small amount of fluid to confirm correct placement of the needle tip. If an intraneural needle tip position is detected, the needle can then be repositioned to prevent injection of a large amount of local anesthetic into the nerve. However, it is unknown if anesthesiologists can accurately discriminate intraneural and extraneural injection of small volumes. Therefore, this study was conducted to determine the diagnostic accuracy of ultrasound assessment using a criterion standard and to compare experts and novices in ultrasound-guided regional anesthesia. METHODS A total of 32 ultrasound-guided infragluteal sciatic nerve blocks were performed on 21 cadaver legs. The injections were targeted to be intraneural (n = 18) or extraneural (n = 14), and 0.5 mL of methylene blue 1% was injected. Cryosections of the nerve and surrounding tissue were assessed by a blinded investigator as "extraneural" or "intraneural." Ultrasound video clips of the injections were reviewed by 10 blinded observers (5 experts, 5 novices) independently who scored each injection as either "intraneural," "extraneural," or "undetermined." RESULTS The mean sensitivity of experts and novices was measured to be 0.84 (0.80-0.88) and 0.65 (0.60-0.71), respectively (P = 0.006), whereas mean specificity was 0.97 (0.94-0.98) and 0.98 (0.96-0.99) (P = 0.53). CONCLUSIONS Discrimination of intraneural or extraneural needle tip position based on an injection of 0.5mL is possible, but even experts missed 1 of 6 intraneural injections. In novices, the sensitivity of assessment was significantly lower, highlighting the need for focused education.
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Güngör I, Zinnuroğlu M, Taş A, Tezer T, Beyazova M. Femoral nerve injury following a lumbar plexus blockade. Balkan Med J 2014; 31:184-6. [PMID: 25207194 DOI: 10.5152/balkanmedj.2014.13179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lumbar plexus blockade (LPB) combined with sciatic nerve block (SNB) is frequently used for lower extremity surgery. Perioperative nerve injury is a rarely encountered complication of peripheral nerve blocks (PNB). CASE REPORT Here we report a 44-year-old male patient who developed a partial femoral nerve injury (FNI) following a LPB which was performed before the surgery of a patellar fracture. The clinical and electroneuromyographic findings of the patient were recovered almost completely within the following six months. CONCLUSION The presented case demonstrated a FNI despite the absence of any pain or paresthesia sensation, with the disappearance of motor response under 0.3 mA of neurostimulation in the experienced hands.
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Affiliation(s)
- Irfan Güngör
- Department of Anesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Murat Zinnuroğlu
- Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayça Taş
- Department of Anesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Tolga Tezer
- Department of Anesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Beyazova
- Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Turkey
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Lopez AM, Sala-Blanch X, Castillo R, Hadzic A. Ultrasound guided injection inside the common sheath of the sciatic nerve at division level has a higher success rate than an injection outside the sheath. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:304-310. [PMID: 24556512 DOI: 10.1016/j.redar.2013.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/06/2013] [Accepted: 11/16/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The recommendations for the level of injection and ideal placement of the needle tip required for successful ultrasound-guided sciatic popliteal block vary among authors. A hypothesis was made that, when the local anesthetic is injected at the division of the sciatic nerve within the common connective tissue sheath, the block has a higher success rate than an injection outside the sheath. METHODS Thirty-four patients scheduled for hallux valgus repair surgery were randomized to receive either a sub-sheath block (n=16) or a peri-sheath block (n=18) at the level of the division of the sciatic nerve at the popliteal fossa. For the sub-sheath block, the needle was advanced out of plane until the tip was positioned between the tibial and peroneal nerves, and local anesthetic was then injected without moving the needle. For the peri-sheath block, the needle was advanced out of plane both sides of the sciatic nerve, to surround the sheath. Mepivacaine 1.5% and levobupivacaine 0.5% 30mL were used in both groups. The progression of motor and sensory block was assessed at 5min intervals. Duration of block was recorded. RESULTS Adequate surgical block was achieved in all patients in the subsheath group (100%) compared to 12 patients (67%) in the peri-sheath group at 30min. Sensory block was achieved faster in the subsheath than peri-sheath (9.1±7.4min vs. 19.0±4.0; p<.001). CONCLUSIONS Our study suggests that for successful sciatic popliteal block in less than 30min, local anesthetic should be injected within the sheath.
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Affiliation(s)
- A M Lopez
- Department of Anesthesiology, Hospital Clínic Barcelona, Barcelona, Spain.
| | - X Sala-Blanch
- Department of Anesthesiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - R Castillo
- Department of Anesthesiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - A Hadzic
- Department of Anesthesiology, St Luke's-Roosevelt Hospital, College of Physicians and Surgeons, Columbia University, New York, USA
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Steuerung der axillären Multiinjektionstechnik zur Plexusanästhesie. Anaesthesist 2014; 63:568-73. [DOI: 10.1007/s00101-014-2319-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/05/2014] [Accepted: 03/08/2014] [Indexed: 11/25/2022]
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Neuburger M, Schwemmer U, Volk T, Gogarten W, Kessler P, Steinfeldt T. [Localization of peripheral nerves. Success and safety with electrical nerve stimulation]. Anaesthesist 2014; 63:422-8. [PMID: 24715260 DOI: 10.1007/s00101-014-2312-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Peripheral electrical nerve stimulation is one of the standard applications in peripheral regional anesthesia in addition to the ultrasound technique. Among other findings, the visualization of needle and nerve during ultrasound-guided blockade caused a change in clinical practice of peripheral nerve stimulation in the last decade. In the present article old and new aspects of principles and clinical practice of the nerve stimulation technique are presented and summarized in a total clinical concept in order to achieve safe and successful peripheral regional anesthesia using electrical peripheral nerve stimulation.
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Affiliation(s)
- M Neuburger
- Abteilung für Anästhesie und Intensivmedizin, Ortenau Klinikum Achern, Josef-Wurzler-Str. 7, 77855, Achern, Deutschland,
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Ultrasound-guided administration of lidocaine into the sciatic nerve in a porcine model: Correlation between the ultrasonographic evolution of the lesions, locomotor function and histological findings. Vet J 2014; 200:170-4. [DOI: 10.1016/j.tvjl.2014.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/30/2014] [Accepted: 01/31/2014] [Indexed: 11/17/2022]
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Procedure-oriented sectional anatomy of the knee. J Comput Assist Tomogr 2014; 38:325-8. [PMID: 24625605 DOI: 10.1097/rct.0b013e3182aaf857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is the fifth in a series of articles related to procedure-oriented joint anatomy. This article reviews the anatomy of the knee and its relationship to procedures in the clinical setting with or without ultrasound/electromyographic guidance. Anatomically correct axial schematics allow injections to be envisioned relative to clinically important anatomy for common knee procedures. Cross-sectional schematics for the knee were drawn as they appear in imaging projections. The levels and planes of cross section were selected to highlight important anatomic landmarks for injection. It is hoped that these schematics allow for safer and more accurate needle procedures in the knee area.
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Ruiz A, Sala-Blanch X, Martinez-Ocón J, Carretero MJ, Sánchez-Etayo G, Hadzic A. Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: a comparison between the out-of-plane versus the in-plane approaches. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:73-77. [PMID: 24314696 DOI: 10.1016/j.redar.2013.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 09/17/2013] [Accepted: 09/25/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND The optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion. METHODS Forty-four patients with hip fracture (American Society of Anaesthesiologists physical status I-III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45-60° angle 1cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2-0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24h. RESULTS The incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p<0.001) (OR=17.5, 95% CI: 4-79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms. CONCLUSIONS Under the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact.
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Affiliation(s)
- A Ruiz
- Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain
| | - X Sala-Blanch
- Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain.
| | - J Martinez-Ocón
- Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain
| | - M J Carretero
- Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain
| | - G Sánchez-Etayo
- Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain
| | - A Hadzic
- Department of Anaesthesia, St Luke's - Roosevelt Hospital Center, University Hospital of Columbia University, New York, USA
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Reina MA, Arriazu R, Collier CB, Sala-Blanch X, Izquierdo L, de Andrés J. Electron microscopy of human peripheral nerves of clinical relevance to the practice of nerve blocks. A structural and ultrastructural review based on original experimental and laboratory data. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:552-562. [PMID: 23938021 DOI: 10.1016/j.redar.2013.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 06/03/2013] [Accepted: 06/04/2013] [Indexed: 06/02/2023]
Abstract
AIM The goal is to describe the ultrastructure of normal human peripheral nerves, and to highlight key aspects that are relevant to the practice of peripheral nerve block anaesthesia. METHOD Using samples of sciatic nerve obtained from patients, and dural sac, nerve root cuff and brachial plexus dissected from fresh human cadavers, an analysis of the structure of peripheral nerve axons and distribution of fascicles and topographic composition of the layers that cover the nerve is presented. Myelinated and unmyelinated axons, fascicles, epineurium, perineurium and endoneurium obtained from patients and fresh cadavers were studied by light microscopy using immunohistochemical techniques, and transmission and scanning electron microscopy. Structure of perineurium and intrafascicular capillaries, and its implications in blood-nerve barrier were revised. RESULTS Each of the anatomical elements is analyzed individually with regard to its relevance to clinical practice to regional anaesthesia. CONCLUSIONS Routine practice of regional anaesthetic techniques and ultrasound identification of nerve structures has led to conceptions, which repercussions may be relevant in future applications of these techniques. In this regard, the ultrastructural and histological perspective accomplished through findings of this study aims at enlightening arising questions within the field of regional anaesthesia.
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Affiliation(s)
- M A Reina
- Department of Clinical Medical Sciences and Applied Molecular Medicine Institute, CEU San Pablo University School of Medicine, Madrid, Spain; Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain.
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The role of electrical stimulation in ultrasound-guided subgluteal sciatic nerve block: a retrospective study on how response pattern and minimal evoked current affect the resultant blockade. J Anesth 2013; 28:524-31. [DOI: 10.1007/s00540-013-1746-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
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Fitó F, Casbas JL, Barbal F, Monsó A. [The "breathing nerve" sign. Subepineural puncture of the sciatic nerve in the popliteal fossa]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:541-542. [PMID: 23276380 DOI: 10.1016/j.redar.2012.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 10/29/2012] [Accepted: 11/02/2012] [Indexed: 06/01/2023]
Affiliation(s)
- F Fitó
- Servei de Anestesia, Hospital de Sant Rafael, Barcelona, España.
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Standard approaches for upper extremity nerve blocks with an emphasis on outpatient surgery. Curr Opin Anaesthesiol 2013; 26:501-8. [PMID: 23787491 DOI: 10.1097/aco.0b013e328362d08a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Currently, no standards exist with regard to the techniques and administration of ultrasound-guided peripheral nerve blocks. Consequently, the techniques and teaching substantially vary among practitioners and institutions. The purpose of this review is to propose a set of standard US-guided techniques for upper extremity nerve blocks. RECENT FINDINGS On the basis of the synthesis of information in available literature and the consensus of an internationally recognized collaborative panel of regional anaesthesia experts, the review recommends a standardized approach to common upper extremity nerve blocks using ultrasound guidance. SUMMARY A set of structured recommendations and approaches are suggested to help standardize clinical practice and teaching of ultrasound-guided upper extremity nerve blocks. Additional emphasis is placed on the discussion of nerve blocks in outpatient surgery.
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Delaunay L, Ecoffey C. [Should we continue to use nerve stimulation alone for peripheral nerve blocks?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:217-9. [PMID: 23506955 DOI: 10.1016/j.annfar.2013.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Distale Blockaden des N. ischiadicus. Anaesthesist 2013; 62:183-88, 190-2. [DOI: 10.1007/s00101-013-2150-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 11/25/2022]
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Sakura S, Hara K. Using ultrasound guidance in peripheral nerve blocks. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Diéguez García P, López Álvarez S, Blanco Dávila R, López González JM, Pensado Castiñeiras A. [Ultrasound-guided block at the antecubital fossa for carpal tunnel syndrome surgery]. ACTA ACUST UNITED AC 2012. [PMID: 23177531 DOI: 10.1016/j.redar.2012.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION There are various anaesthetic techniques for ambulatory surgery of carpal tunnel release. The ultrasound-guided nerve blocks offer advantages compared to other techniques. The purpose of this study was to evaluate the efficacy using ultrasound-guided block at the antecubital fossa, as well as to evaluate complications, patient satisfaction and surgeon satisfaction with the block. MATERIALS AND METHODS Prospective observational study with 32 elective patients for carpal tunnel release in a one-day case unit. An ultrasound-guided block with mepivacaine 1% was performed at the antecubital fossa, aiming for the median, ulnar and the lateral and medial cutaneous nerves of the forearm. The measurements of the anteroposterior and laterolateral diameters of the median and ulnar nerves were recorded, before and after injection. Motor and sensory levels were evaluated for the median and ulnar nerves at 5 and 30 min post injection, and compared with the contralateral hand. Pain from the surgical incision time and recovery were recorded, together with complications, and patient and surgeon satisfaction with the block. RESULTS The antecubital fossa ultrasound-guided block was successful in 93.7% of the patients. No patients needed rescue analgesia in recovery and no complications were recorded. Patient satisfaction was 93.7% and surgeon satisfaction was 97%. CONCLUSIONS A selective block of the medial, ulnar and medial and lateral cutaneous nerves of the forearm are effective and satisfactory anaesthetic techniques for carpal tunnel release in a one-day case unit. It allows early mobilization, minimises risks and amount of local anaesthetic used.
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Affiliation(s)
- P Diéguez García
- Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, Complexo Hospitalario Universitario A Coruña, La Coruña, España.
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Barbal Badia F, Fitó Bertran F, Monsó Molas A. [Peripheral blocks in one-day surgery; contribution of ultrasound]. ACTA ACUST UNITED AC 2012; 60:187-9. [PMID: 23102592 DOI: 10.1016/j.redar.2012.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 07/27/2012] [Indexed: 11/25/2022]
Affiliation(s)
- F Barbal Badia
- Servicio de Anestesia y Reanimación, Hospital Sant Rafael, Barcelona, España.
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Moayeri N, Krediet A, Welleweerd J, Bleys R, Groen G. Early ultrasonographic detection of low-volume intraneural injection. Br J Anaesth 2012; 109:432-8. [DOI: 10.1093/bja/aes208] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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