Complications of peripheral nerve blocks

Neurological Deficits Following Regional Anesthesia and Pain Interventions: Reviewing Current Standards of Care

Regional anesthesia (RA) has become an integral part of modern anesthesia practice and acute pain management strategies. It provides effective pain relief, reduces opioid consumption, and facilitates enhanced recovery after surgery. However, like any medical intervention, RA is not without risks. RA is associated with potential complications, including neurological deficits which can range from mild and transient to severe and permanent. These neurological deficits may result from non-adherence to established standards of care and deviations from the clinical practice guidelines. An online database search was conducted across multiple websites to identify the relevant articles. The inclusion criteria were articles in English, published between January 2010 and July 2024. The search included various study types, such as case series, observational studies, cross-sectional analyses, cohort studies, longitudinal studies, systematic reviews, and practice guidelines. A total of 38 articles met the inclusion criteria and were included in this comprehensive review which examines the neurological complications associated with regional anesthesia and pain interventions, with a particular focus on how deviations from the standards of care contribute to adverse neurological outcomes. Furthermore, it highlights preventive strategies aimed at minimizing the risks of these complications and improving patient safety.

Advanced Hydrogel Systems for Local Anesthetic Delivery: Toward Prolonged and Targeted Pain Relief

Local anesthetics (LAs) have been indispensable in clinical pain management, yet their limitations, such as short duration of action and systemic toxicity, necessitate improved delivery strategies. Hydrogels, with their biocompatibility, tunable properties, and ability to modulate drug release, have been extensively explored as platforms for enhancing LA efficacy and safety. This narrative review explores the historical development of LAs, their physicochemical properties, and clinical applications, providing a foundation for understanding the integration of hydrogels in anesthetic delivery. Advances in thermoresponsive, stimuli-responsive, and multifunctional hydrogels have demonstrated significant potential in prolonging analgesia and reducing systemic exposure in preclinical studies, while early clinical findings highlight the feasibility of thermoresponsive hydrogel formulations. Despite these advancements, challenges such as burst release, mechanical instability, and regulatory considerations remain critical barriers to clinical translation. Emerging innovations, including nanocomposite hydrogels, biofunctionalized matrices, and smart materials, offer potential solutions to these limitations. Future research should focus on optimizing hydrogel formulations, expanding clinical validation, and integrating advanced fabrication technologies such as 3D printing and artificial intelligence-driven design to enhance personalized pain management. By bridging materials science and anesthetic pharmacology, this review provides a comprehensive perspective on current trends and future directions in hydrogel-based LA delivery systems.

Superior hypogastric nerve plexus (SHNP) block for pain management after minimally invasive gynecology surgeries: A prospective randomized controlled trial

OBJECTIVES

Our study aimed to evaluate the effect of superior hypogastric nerve plexus (SHNP) block in postoperative pain management in the first 24 h after minimally invasive gynecological (MIG) surgeries.

METHODS

We conducted a double-blinded, randomized controlled trial in the Department of Obstetrics and Gynecology at a tertiary care centre from May 1, 2023 to September 30, 2023 in women undergoing major MIG surgeries. At the completion of the surgery, women were randomized to the intervention group who received SHNP block with ropivacaine 10 mL (0.75%) before port removal, whereas no intervention was taken in the control group. The extubation time was noted, and the pain score was assessed after 1, 2, 6, 12, and 24 h of extubation in the postoperative period using the visual analog scale (VAS). Statistical analysis was done, with a significance level of 0.05, to test the differences between the two groups.

RESULTS

A total of 64 patients were randomly allocated to intervention and control groups. The median pain score was lower at 1 and 2 h post-extubation and comparable between the two groups at 6, 12, and 24 h. The surrogate markers that is need for additional analgesia and duration of stay did not differ significantly in the two groups, with P-values of 0.08 and 0.943, respectively.

CONCLUSION

Although the SHNP group experienced considerably lower immediate postoperative pain levels in the initial hours following extubation, the impact of this benefit remains uncertain in the longer postoperative period. The effectiveness of this modality for pain control needs further study, particularly at later postoperative hours.

Effects of Genicular Nerve Blocks in Combination With an Adductor Canal Block in Patients Undergoing Arthroscopic Knee Surgery: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Arthroscopic knee surgery is increasingly popular. Optimal postoperative pain management enhances patient satisfaction and minimizes hospitalization. Numerous studies have demonstrated the benefits of adductor canal blocks (ACBs) and genicular nerve blocks (GNBs) in postoperative analgesia. This study aims to evaluate the efficacy of adding GNBs to an ACB in reducing postoperative pain scores compared to an ACB alone. Additionally, it seeks to compare secondary outcomes, including opioid consumption, motor blockade, nausea and vomiting, rash, and itching during the postoperative period.

METHOD

This prospective, randomized, controlled clinical trial included 49 patients undergoing arthroscopic knee surgery. The study group received a GNB with 0.25% bupivacaine (3 mL) at each quadrant of the knee, except for the inferolateral quadrant, in combination with an ACB using 0.25% bupivacaine (20 mL). The control group received an ACB alone. Fentanyl (1-2 mcg/kg IV) was administered as rescue analgesia during the perioperative period. Pain scores (visual analog score (VAS)), cumulative opioid consumption, motor blockade, and incidences of postoperative nausea and vomiting (PONV) and itching were assessed at six, 12, 24, and 48 hours postoperatively.

RESULTS

No statistically significant differences in median pain scores were observed between the groups. However, postoperative opioid consumption was significantly lower in the study group, with median values (interquartile range (IQR)) of 0 (0, 30) at 12, 24, and 48 hours postoperatively compared to the control group (p ≤ 0.001). Additionally, no significant differences were found between groups regarding motor blockade or opioid-related side effects.

CONCLUSION

Adding GNBs to an ACB did not demonstrate superiority in reducing postoperative pain scores. However, it effectively reduced perioperative opioid consumption at 12 to 48 hours postoperatively without increasing adverse effects such as nausea, vomiting, or motor blockade. These findings highlight the potential of GNBs as a valuable component of postoperative pain management strategies for arthroscopic knee surgery.

Analgesic effectiveness of continuous versus single-injection adductor canal block in addition to continuous popliteal sciatic nerve block for bimalleolar and trimalleolar ankle fracture surgery: Prospective randomized controlled trial

BACKGROUND

The adductor canal block is a well-known procedure for controlling postoperative pain after medial malleolus fracture surgery. Continuous nerve block is a viable option for blocking pain for a longer period although the literature on this subject is scarce. Therefore, this study aimed to compare continuous adductor canal block (cACB) group to single-injection adductor canal block (sACB) group in those with bimalleolar or trimalleolar ankle fractures. The procedure was performed in addition to a continuous sciatic nerve block for postoperative pain relief and patient satisfaction.

METHODS

The study included 57 patients who had bimalleolar or trimalleolar ankle fractures and underwent open reduction and internal fixation between August 2016 and June 2018. Each patient received a continuous sciatic nerve block and was divided into two groups: those who received cACB and those who received sACB. Each postoperative pain was scored at 4, 8, 12, 24, 48, and 72 h after surgery. Additionally, the consumption of rescue medications and patient satisfaction were evaluated.

RESULTS

The two groups displayed no disparity in medial side ankle pain at 4 h and 8 h after surgery, but significantly higher pain in the sACB group at 12, 24, 48, and 72 h after surgery. However, there was no difference in the pain at the lateral side of ankle and consumption of rescue medication. In addition, the cACB group showed more satisfaction than the sACB group did.

CONCLUSION

CACB is better than sACB in terms of postoperative pain control and patient satisfaction. cACB can be used for postoperative pain control in ankle fractures involving the medial malleolus.

LEVEL OF EVIDENCE

Prospective Randomized Controlled Trial, Level 2.

Advances in the use of local anesthetic extended-release systems in pain management

Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.

Anterograde Intramedullary Nailing without Bone Grafting for Humeral Shaft Nonunion Associated with Early Exploration of Secondary Radial Nerve Palsy: A Case Report

BACKGROUND

Humeral shaft fractures are relatively common. Complications associated with this type of fracture and its treatment include nonunion and radial nerve palsy. Plate osteosynthesis with autologous bone grafting is considered the gold standard for treating nonunion. However, bone grafts might not always be necessary in cases of hypertrophic nonunion, and treatment should be tailored to the specific type and characteristics of the nonunion. The treatment of radial nerve palsy is debated, with some favoring expectant management based on the nerve's ability to regenerate, and others preferring early surgical exploration to prevent possible lasting nerve damage.

METHODS

We present the case of a 46-year-old male patient with a six-year-old humeral shaft fracture resulting in hypertrophic nonunion. We treated the nonunion with anterograde intramedullary nailing without bone grafting. Postoperatively, the patient developed severe radial nerve palsy. After repeated electrophysiological studies, a decision was made to surgically explore the nerve 10 days after the nonunion surgery. The nerve was subsequently found to be intact and treated with neurolysis.

RESULTS

Bony union was shown at six months after nonunion surgery. Four months after the nonunion surgery, the patient started to show clinical signs of nerve recovery, and at 12 months he achieved nearly full clinical recovery of radial nerve function.

CONCLUSIONS

Anterograde intramedullary nailing without autologous bone grafting may be considered an option for treating hypertrophic nonunion. The management of radial nerve palsy requires effective cooperation and communication between patient and physician. Further research is necessary to be able to better predict nerve recovery.

Ultrasound-guided sciatic nerve block injections in barred owl (Strix varia) cadavers

OBJECTIVE

To describe an ultrasound-guided approach to the sciatic nerve and the distribution of nerve staining using two injectate volumes of dye in barred owls.

STUDY DESIGN

Descriptive, randomized, assessor-blinded, cadaveric study.

ANIMALS

Twelve barred owl cadavers.

METHODS

The sciatic nerve was visualized with a 13-6 MHz linear ultrasound probe placed on the medial aspect of the proximal femur in barred owl cadavers. A needle was inserted at the proximal caudal thigh, and cranially advanced in-plane until the tip was immediately adjacent and ventral to the sciatic nerve. Eleven owls were injected bilaterally with a 1:1 solution of 1% methylene blue and 0.5% ropivacaine, with high-volume (HV; 0.4 mL kg-1) and low-volume (LV; 0.2 mL kg-1) treatments. Nerve staining ≥ 1 cm circumferentially was determined by dissection 15 minutes post-injection. The coelom was then opened to inspect for aberrant dye spread. In one barred owl cadaver, a 1:1 solution of 1% methylene blue and 74% ioversol contrast was injected, and computed tomography was performed immediately before and 15 minutes after injection for evaluation of injectate spread.

RESULTS

The HV treatment (0.4 mL kg-1) resulted in successful nerve staining in 100% of injections, whereas the LV treatment (0.2 mL kg-1) resulted in successful nerve staining in 91% of injections. There was no leakage of injectate into undesired locations (e.g. coelomic cavity) in any cadaver.

CONCLUSIONS AND CLINICAL RELEVANCE

In barred owls, the sciatic nerve can be visualized with ultrasound and injecting a ropivacaine/dye solution under ultrasound guidance successfully stained the sciatic nerve in the majority of cases. This technique holds potential for providing analgesia distal to the stifle joint; however, further investigations are necessary to evaluate its practical application in a clinical setting.

Physical harms associated with suprascapular nerve block interventions in the non-surgical management of acute and chronic shoulder pain: A systematic review

Background

The utility of the suprascapular nerve block (SSNB) in the non-surgical management of shoulder pain continues to be explored, whilst its associated physical harms have not. This systematic review aims to report the physical harms associated with the SSNB in the non-surgical management of shoulder pain.

Methods

A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline, Pubmed, and Scopus databases. Studies were included if they reported the presence or absence of harm following a SSNB intervention (injection, pulsed radiofrequency, ablation) in the non-surgical management of acute or chronic shoulder pain. Excluded studies were those which utilised SSNB for peri, intra, or post-surgical intervention. The McMaster tool for assessing quality of harms assessment and reporting was utilised.

Results

A total of 111 studies were included in this review of which 168 episodes of harm were reported across 4142 participants. Harm severity ranged from pneumothorax (n = 5) to local pain and bruising (n = 50). The quality of harms assessment and reporting across all studies was poor.

Discussion

Despite heterogeneity in SSNB intervention, and low-quality evidence, SSNB carries a low risk of physical harm. Further work is needed in addressing the poor quality of harms assessment and reporting in SSNB studies.

Functional recovery of wrist surgery with regional versus general anesthesia: a prospective observational study

PURPOSE

Regional anesthesia may favour postoperative rehabilitation by inhibiting peripheral sensitization and secondary hyperalgesia. The literature on this subject is limited. In the present FUNCTION study, we sought to compare the functional recovery post orthopedic wrist surgery with regional versus general anesthesia.

METHODS

We conducted a single-centre prospective observational cohort study in adult patients with a distal radial fracture. Functional recovery was assessed with validated psychometrics questionnaires (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Patient-Rated Wrist Evaluation [PRWE]), range of motion, and grip strength. We used a linear mixed regression model to assess the impact of the anesthesia technique on functional recovery. Postoperative pain and patient satisfaction were evaluated using a visual analog scale.

RESULTS

We recruited 76 patients. At 12 weeks post surgery, there was no difference between the type of anesthesia and functional recovery with the QuickDASH (higher scores worse; regional anesthesia [RA], 22.7 vs general anesthesia [GA], 19.3; adjusted mean difference [aMD], -0.3; 95% confidence interval [CI], -9.6 to 9.0; P = 0.9) and PRWE (higher scores worse; RA group, 21.0 vs GA group, 20.5; aMD, -3.3; 95% CI, -12.1 to 5.6; P = 0.93) questionnaires. Range of motion, satisfaction, and postoperative pain were similar between groups. Right-hand grip strength was higher in the GA group.

CONCLUSION

Regional anesthesia was not associated with improved functional recovery compared with general anesthesia. The dominance of the operated limb was a confusion factor in all evaluation modalities. Further research taking into account the dominance of the hand is necessary to establish the effects of regional anesthesia on functional recovery.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04541745); registered 9 September 2020.

Sustained release local anesthetics for pain management: relevance and formulation approaches

This review attempted to ascertain the rationale for the formulation of sustained-release local anesthetics and summarize the various formulation approaches designed to date to achieve sustained and localized local analgesic effects. The incidence of pain, which is the concern of patients as well as health care professionals, is increasing due to accidents, surgical procedures, and other diseases. Local anesthetics can be used for the management of moderate to severe acute and chronic pain. They also allow regional analgesia, in situations where the cause and source of the pain are limited to a particular site or region, without the need for loss of consciousness or systemic administration of other analgesics thereby decreasing the risk of potential toxicities. Though they have an interesting antipain efficacy, the short duration of action of local anesthetics makes the need for their multiple injections or opioid adjuvants mandatory. To overcome this problem, different formulations are being designed that help achieve prolonged analgesia with a single dose of administration. Combination with adjuvants, liposomal formulations, lipid-based nanoparticles, thermo-responsive nanogels, microspheres, microcapsules, complexation with multivalent counterions and HP-β-CD, lipid-based nanoparticles, and bio-adhesive films, and polymeric matrices are among the approaches. Further safety studies are required to ensure the safe and effective utilization of sustained-release local anesthetics. Moreover, the release kinetics of the various formulations should be adequately established.

Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study

INTRODUCTION

Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases.

RESULTS

The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported.

DISCUSSION

These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.

Topographical anatomy of the mandibular foramen in the dromedary camels (Camelus dromedarius): an extraoral approach for the inferior alveolar nerve blocks

Understanding the clinical anatomy of the head is essential for performing proper inferior alveolar nerve (IAN) block anesthesia to facilitate invasive dental procedures in camels. However, osteometric data related to the IAN in camels are lacking. This study was carried out to accurately locate the mandibular foramen (MF) and the course of the IAN in the camel head and to establish an approach for its localization in clinical practice. To achieve these aims, eight osteometric measurements were used to determine the location of the MF in relation to its surrounding structures in six cadaveric skulls of adult camels. Four camel heads were dissected, and the course of the IAN inside the mandibular canal was studied. In addition, four heads were used as a trial for the extraoral approach to the IAN block using contrast radiographs based on established metric indices. Dissection of the four camel heads revealed that the MF was located near the intersection of two lines passing through the occlusal surface of the mandibular cheek teeth and at the midpoint of the zygomatic process of the temporal bone. Significant differences were not observed between the right and left mandibles. Successful deposition of the contrast medium near the MF was observed in all examined specimens. This study reports a new, simple approach to reaching the IAN at the MF. However, further clinical validation of the proposed technique is required.

Regional anesthesia is associated with improved metastasis free survival after surgical resection of bone sarcomas

There is increasing evidence that perioperative factors, including type of anesthesia, may be an important consideration regarding oncological disease progression. Previous studies have suggested that regional anesthesia can improve oncological outcomes by reducing the surgical stress response that occurs during tumor resection surgery and that may promote metastatic progression. The purpose of this study is to provide the first robust investigation of the impact of adding regional anesthesia to general anesthesia on oncological outcomes following sarcoma resection. One hundred patients with bone sarcoma were retrospectively analyzed in this study. After adjusting for confounding variables such as age and grade of the tumor, patients with bone sarcoma receiving regional anesthesia in addition to general anesthesia during resection had improved metastasis free survival (multivariate hazard ratio of 0.47 and p = 0.034). Future studies are needed to confer the beneficial effect of regional anesthesia, and to further investigate the potential mechanism. Clinical significance: The results from this study provide evidence that regional anesthesia may be advantageous in the setting of bone sarcoma resection surgery, reducing pain while also improving oncological outcomes and should be considered when clinically appropriate.

Femoral nerve blockade during endovenous laser ablation of great saphenous vein decreases pain but does not affect the use of opioids during the procedure

BACKGROUND

Endovenous laser ablation (EVLA) using tumescent anesthesia for treatment of an insufficient great saphenous vein (GSV) can be painful and require intravenous pain management and, sometimes, sedation with propofol. Femoral nerve blockade (FNB) anesthetizes the femoral nerve distribution and is usually used for anterior thigh and knee procedures. It is easy to inject with ultrasound guidance because the nerve is easy to visualize in the groin. The aim of the present double-blind, randomized controlled trial was to determine whether FNB before tumescent anesthesia decreases the pain of GSV EVLA combined with local phlebectomy.

METHODS

Eighty patients who underwent GSV EVLA combined with local phlebectomy under tumescent anesthesia were randomized into two groups. The placebo group (control group; 40 patients) was given placebo FNB with 0.9% saline before tumescent injection. The FNB group (intervention group; 40 patients) received 1% lidocaine with adrenaline for FNB before tumescent injection. Only the study nurse, who performed the randomization, knew which patients were in which group. The patients and operating surgeon were unaware of the randomization group. FNB was performed under ultrasound guidance. The effectiveness of anesthesia was tested 10 minutes after injection using the pin-prick test and a numeric rating scale (NRS). The NRS was completed before and during tumescent anesthesia and during EVLA ablation and local phlebectomy. The motor function of the femoral nerve was tested at the end of the procedure and 1 hour after using the Bromage method. Patients had a follow-up visit 1 month after the procedure, and their need for pain medication and the duration of sick leave were recorded.

RESULTS

No differences were found in the gender distribution, age, or GSV dimensions at baseline. The mean length of the treated GSV segment was 28 cm and 30 cm and the mean energy used was 1911 J and 2059 J in the placebo and FNB groups, respectively. The median NRS score for pain during tumescent injection around the GSV was 2 (interquartile range [IQR], 1-4) in the placebo group compared with 1 (IQR, 1-3) in the FNB group. Very little pain was experienced during laser ablation. The median NRS score was 0 (IQR, 0-0) and 0 (IQR, 0-0.75) in the placebo and FNB groups, respectively. The most painful stage was injection of tumescence to the local phlebectomy sites in both groups. The median NRS score was 4 (IQR, 3-7) in the placebo group and 2 (IQR, 1-4) in the FNB group (P = .01). During local phlebectomy, the NRS score was 2 (IQR, 0-4) vs 1 (IQR, 0-3) in the placebo and FNB groups, respectively. Only the difference in pain during injection of tumescence before local phlebectomy was significant.

CONCLUSIONS

FNB seems to decrease pain during EVLA combined with local phlebectomy. Patients experienced the highest pain when tumescence was injected before local phlebectomy, and those in the FNB group experienced significantly less pain than the placebo group. No indication for routine use of FNB is indicated. However, it could be used to decrease the pain for patients who experience strong pain during varicose vein surgery, especially if extensive local phlebectomies are required.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

INTRODUCTION

Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial.

METHODS AND ANALYSIS

WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks.

TRIAL REGISTRATION NUMBER

ISRCTN identifier: 15052559.

The effect of pregabalin on postoperative pain after anterior cruciate ligament reconstruction: A systematic review of randomized clinical trials

Background

Despite the enormous success of anterior cruciate ligament (ACL) reconstruction, acute neuropathic pain can develop postoperatively and is both distressing and difficult to treat once established. Pregabalin, an anticonvulsant agent that selectively affects the nociceptive process, has been used as a pain relief agent. The purpose of this systematic review of randomized controlled trials (RCTs) was to evaluate the pain control effect of pregabalin versus placebo after ACL reconstruction.

Method

A search of the literature was performed from inception to June 2022, using PubMed, Scopus, Google Scholar, Web of Science, Cochrane and EBSCO. Studies considered for inclusion were RCTs that reported relevant outcomes (postoperative pain scores, cumulative opioid consumption, adverse events) following administration of pregabalin in patients undergoing ACL reconstruction.

Result

Five placebo-controlled RCTs involving 272 participants met the inclusion criteria. 75 mg and 150 mg oral pregabalin was used in included trials. Two studies used a single dose of pregabalin one hour before anesthesia induction. Two studies used pregabalin 1 hour before anesthesia induction and 12 hours after. One study used daily pregabalin 7 days before and 7 days after surgery. Out of five papers, three papers found significantly lower pain intensity and cumulative opioid consumption in pregabalin group compared with placebo group. However, a decrease in pain scores was found in all trials. Pregabalin administration was associated with dizziness and nausea.

Conclusion

The use of pregabalin may be a valuable asset in pain management after ACL reconstruction. However, future studies with larger sample size and longer follow-up period are required.

Safety of Cubital Tunnel Release Under General versus Regional Anesthesia

Purpose

The aim of this study was to evaluate the occurrence of early (<6 weeks) post-operative complications following ulnar nerve decompressions at the cubital tunnel performed under regional anesthesia compared to those performed under general anesthesia.

Methods

In situ ulnar nerve decompressions at the cubital tunnel performed at a single institution from 2012 through 2019 were retrospectively reviewed. Post-operative complications were compared between subjects who underwent the procedure with regional versus general anesthesia.

Results

Ninety-one ulnar nerve in situ decompressions were included in the study, which were performed under regional anesthesia in 55 and general anesthesia in 36 cases. The occurrence of post-operative complications was not significantly different between patients who received regional (n = 7) anesthesia and general (n = 8) anesthesia. None of the complications were directly attributed to the type of anesthesia administered. The change in pre- and post-operative McGowan scores were not significantly different between anesthesia groups (p = 0.81).

Conclusion

In situ ulnar nerve decompression at the cubital tunnel under regional anesthesia does not result in increased post-operative complications compared to those surgeries performed under general anesthesia. In situ ulnar nerve decompression performed under regional anesthesia is a safe and reliable option for patients who wish to avoid general anesthesia.

Level of Evidence

III.

"Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part C (Prevention of Nerve Injuries)

"A clever person solves the problem. A wise person avoids it" (Albert Einstein). There is no convincing evidence that any modality 100% effectively prevents nerve injury. The risk of nerve injury remains the same even with the ultrasound due to limitations in the resolution of images and inter-operator and inter-patient differences. In a nutshell, caution is required when dealing with precious nerves in the perioperative period, either during peripheral nerve blocks (PNBs), patient positioning, or surgery. Identifying pre-existing nerve injury, either due to trauma or an existing neuropathy, and preventing further nerve injury should be an important goal in providing safe regional anesthesia (RA). Multimodal monitoring is key to avoiding multifactorial nerve injuries. The use of triple guidance (ultrasound + peripheral nerve stimulator + injection pressure monitor) during PNBs further improves the safety of RA. The ultrasound helps in real-time visualization of the nerve, needle, and drug spread; the peripheral nerve stimulator helps confirm the target nerves; and the injection pressure monitor helps avoid nerve injury. Such multimodalities can also give the confidence to administer PNB without risk of nerve injury. This article is part of the comprehensive overview of the essential understanding of peripheral nerves before blocking them. It describes various preventive measures to avoid peripheral nerve injuries while administering PNBs. It will help readers understand the importance of prevention in each step to avoid perioperative PNIs.

A prospective, randomised, single-blinded controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory upper limb surgeries

Background

Interscalene block is usually performed using either ultrasound (US) or nerve stimulator (NS) guidance. This single-blinded, prospective, randomised study was performed to find out whether US was able to offer distinct advantages over conventional NS guidance.

Methods

100 patients in the American Society of Anaesthesiology (ASA) physical status I to III, aged 18-70 years were randomised into US guided or NS guided group for interscalene block with 15 ml 0.5% bupivacaine and 5 ml 2% lignocaine. Patients were premedicated with midazolam 0.03 mg/kg (maximum 2 mg) and fentanyl 2 mcg/kg (max 100 mcg) was used as rescue analgesia.

Result

Mean time of onset of sensory block in the NS group was 6.2 min (3.1), the US group 4.7 min (1.1), p value (<0.001). Mean duration of post-operative analgesia in NS group 323.6 min (98.6), US group 558.6 min (144.3), (p < 0.001). Mean time for performance of block NS Group 7.3 min (2.0), and in the US group 4.9 min (1.3), (p < 0.001). Number of needle passes NS group 1.7(0.9), US group 1.3 (1.0), (p < 0.005). Total cost per surgery with NS was Rs 363.10 less than in the US-guided block. Incremental cost effectiveness ratio for ultrasound group for onset of block was Rs -242.07, Rs 92.0 for duration of block and Rs -151.29 for time for performance of block. No incident of post-operative neurological complications seen in either group.

Conclusion

Ultrasound use offers faster onset, longer duration of block, reduces time for performance of blocks with comparable complication rates. For most of the measured parameters it was superior but more costly than nerve stimulator for directly measured costs.

Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review

BACKGROUND

Peripheral nerve block is a common anesthetic technique used during orthopedic upper limb surgery. Injection of local anesthetics around the target nerve inhibits the action of voltage-dependent sodium channels, inhibiting neurotransmission of pain impulses and providing motor immobility. Compared to general anesthesia, it could improve functional recovery by inhibiting nociceptive impulses and inflammation, thus reducing postoperative pain and immobilization and improving postoperative rehabilitation. This systematic review evaluates the impact of peripheral nerve block versus general anesthesia on postoperative functional recovery following orthopedic upper limb surgery.

METHODS

We searched CENTRAL, MEDLINE, CINHAL, EMBASE, and Scopus trial databases from inception until September 2021 for studies comparing peripheral nerve block to general anesthesia. We collected data on functional recovery, range of motion, patient satisfaction, quality of life, and return to work. We pooled studies using a random-effects model and summarized the quality of evidence with the GRADE approach.

RESULTS

We assessed 373 citations and 19 full-text articles for eligibility, and included six studies. Six studies reported on functional recovery, but failed to detect a significant superiority of peripheral nerve block over general anesthesia (3 RCT studies, N = 160; SMD -0.15; CI at 95% -0.60-0.3; I2 = 45%; p = 0.07; low quality of evidence and 3 observational studies, N = 377; SMD -0.35; CI at 95% -0.71-0.01; I2 = 64%; p = 0.06; very low quality of evidence).

CONCLUSIONS

Current literature is limited and fails to identify the benefit of peripheral nerve block on functional recovery. More studies are needed to assess the impact on long-term recovery. Considering the potential impact on clinical practice and training, a prospective study on functional recovery is ongoing (NCT04541745).

TRIAL REGISTRATION

PROSPERO ID CRD42018116298. Registered on December 4, 2018.

Multimodal Approach in Minimizing Transient Neurological Complications Following Single Shot Brachial Plexus Block: A Prospective Observational Study

PURPOSE

The aim of the study was to assess the benefit of a using multimodal approach, including injection pressure monitoring (IPM) and different techniques of nerve localization, with respect to complications following single-shot brachial plexus block (SSBPB).

METHODS

In this study, 238 adults (132 males and 106 females) undergoing upper-limb surgeries under peripheral nerve block (PNB) were evaluated. Of these, 198 patients were given supraclavicular block, and 40 patients received interscalene block using either ultrasound (USG) and peripheral nerve stimulation (PNS) or PNS alone. Injection pressure monitoring was used in 216 patients.

RESULTS

Transient neurological deficit (TND) was observed in six out of 198 patients where USG and NS were used along with IPM as opposed to 12 out of 18 patients without IPM (p<0.0001). In patients where only PNS was used, transient neurological deficit (TND) was seen in six out of 18 patients with IPM as opposed to all the patients (n=4) without IPM (p<0.02). Among the patients where injection pressure was monitored, six out of 198 patients developed TND when both USG and NS were used, compared to six out of 18 patients where only PNS was used (p<0.007).

CONCLUSION

Use of injection pressure monitoring along with different nerve localization techniques results in fewer transient neurological deficits.

Peripheral Nerve Block Practice in Portugal: A National Survey

Regional anesthesia (RA) has several benefits and its use has increased with the advent of ultrasound-guided techniques. Opioid-sparing anesthesia and reduced use of general anesthesia are some of the mainstay advantages of RA. Although anesthetic practices differ deeply between countries, RA has assumed a crucial role in the daily practice of anesthesiologists, particularly during the COVID-19 pandemic period. This cross-sectional study provides an overview of peripheral nerve block (PNB) techniques performed in Portuguese hospitals. An online survey was reviewed by members of Clube de Anestesia Regional (CAR/ESRA Portugal) and then sent to a national mailing list of anesthesiologists. The survey focused on specific topics related to RA techniques such as the importance of training and experience, and the relevance of logistical limitations during the execution of RA. All data were collected anonymously and included in a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) database, for further analysis. A total of 335 valid answers were obtained. All participants considered RA as a key competence in their daily practice. Half of those inquired performed PNB techniques once to twice per week. The main limitations identified for performing RA in Portuguese hospitals were the absence of block rooms and insufficiently trained personnel for the appropriate and safe execution of these techniques. This survey provides a comprehensive overview of RA in the Portuguese setting and could serve as a baseline for further studies.

No Benefit of Adductor Canal Block Compared with Anterior Local Infiltration Analgesia in Primary Total Knee Arthroplasty: A Single-Blinded Randomized Controlled Clinical Trial

BACKGROUND

An adductor canal block (ACB) performed by an anesthesiologist is an established component of analgesia after total knee arthroplasty. Alternatively, surgeons may perform periarticular local infiltration analgesia (LIA) intraoperatively. We hypothesized that ACB would be superior to anterior LIA in terms of morphine consumption in the first 48 hours after primary total knee arthroplasty under spinal anesthesia.

METHODS

This prospective controlled and blinded trial included 98 patients; 48 received an ACB plus sham (saline solution) anterior LIA, and 50 received a sham (saline solution) ACB plus anterior LIA. Both groups received posterior LIA with local anesthetic. The primary outcome was cumulative morphine consumption at 48 hours after surgery. Secondary outcomes were pain while resting, standing, and walking, rehabilitation scores, opioid-related side effects, and patient satisfaction.

RESULTS

No difference in the primary outcome was found, and the 48-hour morphine consumption was low in both arms (28.8 ± 17.6 mg with ACB, 26.8 ± 19.2 mg with anterior LIA; p = 0.443). Pain scores were significantly better in the anterior LIA arm, but the differences were not clinically relevant. There were no differences in any other secondary outcome measures.

CONCLUSIONS

LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of a Novel Approach

Introduction

External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under general anaesthesia in an operating theatre. This practice is resource-intensive and limits the amount of time available for other surgical cases in the operating theatre. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate the EF removal in an outpatient setting.

Design and methods

This prospective case series evaluated the first 50 consecutive cases of EF removal in the outpatient clinic between 10/06/22 and 03/02/23. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirements and then were asked to evaluate their experience and perceived pain using the visual analogue scale (VAS).

Results

Fifty patients were included in the study. The mean age was 46.8 years (range 21-85 years). About 54% of the patients were male patients (N = 27). Post-procedure, all patients indicated positive satisfaction ratings, each participant responded as either 'satisfied' (N = 6), 'very satisfied' (N = 24) or 'highly satisfied' (N = 20). In addition, 90% of the participants reported that they would opt for this method of EF removal again in future. The VAS for pain immediately following completion of the procedure was low, with a mean score of 0.36 (range 0-4), where a score of 0 = 'No pain', and 10 = 'worst pain possible'. The median score was 0.

Conclusion

We present the first description of outpatient EF removal using regional anaesthesia, with a prospective case series of 50 fully conscious patients from whom the EF was removed. This novel technique is likely to be cost-effective, reproducible, and safe. This technique reduces the burden of EF removal from an operating list and also improves the patient's experience when compared with other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this technique also demonstrates a method of improving environmental sustainability.

How to cite this article

Williams LM, Stamps G, Peak H, et al. Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of A Novel Approach. Strategies Trauma Limb Reconstr 2023;18(1):7-11.

Ultrasound-guided femoral block in patients undergoing radiofrequency ablation of incompetent saphenous veins: A randomized controlled trial

OBJECTIVE

To evaluate the benefit of ultrasound-guided femoral nerve block (UGFN) for reducing pain in patients undergoing radiofrequency ablation (RFA).

METHODS

Patients age 18-70 years scheduled for RFA were prospectively enrolled. Patients were randomly assigned to the UGFN or control group at a 1:1 ratio, and stratified according to concomitant phlebectomy procedure. The pain score and amount of fentanyl use during the operation were recorded. Pain severity and quadriceps muscle strength were recorded at 2-, 6-, and 12-hours postoperation.

RESULTS

Twenty-four patients in each group were included. Moderate to severe pain during surgery was found in 16 (66.7%) patients in the control group, and in 2 (8.3%) patients in the UGFN group (p < 0.001). Fentanyl use during surgery was significantly higher in controls than in UGFN patients (107.29 ± 40.70 μg vs. 42.71 ± 26.04 μg, respectively; p < 0.0001). The postoperative pain score was not significantly different between groups. In the UGFN group, quadriceps femoris weakness was found in 19 (79.2%) patients, and in 1 (4.2%) patient at 2-hours and 6-hours postoperation, respectively. No patient in the control group had quadriceps femoris weakness.

CONCLUSION

UGFN decreased intraoperative pain during RFA. However, patients undergoing UGFN should be observed in the hospital for at least 6 hours, and quadriceps muscle power should be tested before hospital discharge.

Sedation efficacy of different dose of remimazolam with sufentanil for nerve block in young and elderly patients: a randomized, controlled study

Purpose

Anxiety and pain commonly occur during nerve block, we aimed to investigate the sedation efficacy of different doses of remimazolam with sufentanil in young and elderly patients.

Methods

In this randomized trial, patients aged 18–85 years who underwent nerve block was enrolled. All patients received sufentanil 0.08 μg/kg for analgesia. Young patients (age < 65 years) were randomized into the control group (Group C, 0.9% saline), medium-dose remimazolam (Group M, 0.06 mg/kg) and high-dose remimazolam group (Group H, 0.08 mg/kg). Elderly patients (age ≥ 65 years) were randomized into the Group C, low-dose remimazolam group (Group L, 0.04 mg/kg) and Group M. Primary outcome was the success rate of procedure sedation. Respiratory depression and hypoxia were the interested safety outcomes.

Results

Ninety young and 114 elderly patients were enrolled, respectively. In comparison with Groups C and M, young patients in Group H had the highest success rate of procedure sedation (80.0 vs. 73.3 vs. 43.3%, P = 0.006). Elderly patients in Groups M and L had similar success rates of procedure sedation, which were significantly higher than that in Group C (78.9 vs. 78.9 vs. 50.0%, P = 0.007). In elderly patients, the incidence of respiratory depression and hypoxia tended to be higher in Group M than those in Groups L and C (both P < 0.001).

Conclusion

Remimazolam 0.08 mg/kg provided the best sedation efficacy in young patients while remimazolam 0.04 mg/kg with the trend of less respiratory adverse events was more optimal for elderly patients.

Trial registration

http://www.chictr.org.cn/showproj.aspx?proj=122016.

Treatment of Brachial Plexitis: A Complication of Brachial Plexus Regional Nerve Block

Brachial plexitis is a rare condition characterized by inflammation within the brachial plexus presenting with acute shoulder pain, with motor and sensory deficits of the upper extremity. This case involves a 56-year-old female presenting with brachial plexitis after undergoing rotator cuff repair with a regional nerve block to the right brachial plexus. The diagnosis was made on her clinical presentation of fever with swelling and pain over her right shoulder and imaging showing inflammation and abscess formation with the soft tissue. The case was managed with antibiotic therapy and ultrasound drainage of the abscess.

Although this case is a rare occurrence, the likely etiology was secondary to peripheral nerve catheter placement for anesthesia, as well as her probable immunocompromised state with underlying uncontrolled diabetes mellitus. Surgical intervention was avoided because of the high probability of intraoperative complications due to the abscess’s location and thus management opted for less invasive measures.

Therefore, brachial plexitis with abscess formation is a complication of plexus nerve block, can present without any neurological deficit and is best managed conservatively without surgery.

Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice?

The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery

INTRODUCTION

Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand.

METHODS

This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05).

DISCUSSION

In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Hip Fracture Surgery: Regional Anesthesia and Opioid Demand

BACKGROUND

Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery.

METHODS

This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables.

RESULTS

After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand.

DISCUSSION

RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

High-Efficiency Ultrasound-Guided Regional Nerve Block Workshop for Emergency Medicine Residents

Audience

This small-group workshop is designed for emergency medicine residents. This workshop can also be offered to medical students or faculty interested in reviewing and practicing ultrasound-guided regional nerve blocks.

Introduction

Ultrasound-guided regional nerve block (UGRNB) is a method used to administer local anesthesia to otherwise unreachable locations on the body and may be used in the management of various painful conditions seen in the emergency department. The ultrasound curriculum of our residency program is longitudinal. All residents spend time with the ultrasound director throughout their training, engage in daily bedside ultrasound, and have regular skills training on the various clinical applications of ultrasound. Additionally, all residents have a required ultrasound rotation dedicated to performing bedside ultrasound in the Emergency Department. Although others have outlined approaches to teaching emergency medicine residents the techniques needed to perform UGRNBs, the value of taking a one-day, high-efficiency teaching strategy with a narrow focus on practical application has yet to be appreciated.

Educational Objectives

The objective of this workshop is to provide emergency medicine residents the confidence and skill sets needed to effectively perform five commonly used UGRNBs for conditions encountered in the emergency department. Through this one-day, accelerated workshop, residents will be given an opportunity to sharpen their UGRNB technique prior to applying them in the clinical environment. By the end of this workshop, learners will be able to: 1) recognize the clinical situations in which UGRNBs can be utilized and understand the associated risks, 2) list the commonly used local anesthetic medications and their proper dosing in respect to regional nerve blocks, 3) demonstrate proper ultrasound probe positioning and identify relevant anatomical landmarks for each nerve block on both standardized patients and cadavers, 4) describe the common steps involved to perform each nerve block, 5) perform the five UGRNB techniques outlined in this workshop.

Educational Methods

Small group activity combining didactic learning, case-based learning, and procedural simulation. The didactic component may be delivered in an asynchronous learning or "flipped classroom" format.

Research Methods

In-person interviews of the learners were obtained following the debriefing session during which they were asked about their enjoyment and satisfaction with the workshop. In addition, learners were asked about the value of the activities for their clinical practices and to provide formative feedback regarding the design of the workshop.

Results

Overall, participants reported high levels of enjoyment, and many verbalized their satisfaction with the expeditious and pragmatic nature of the workshop. Some participants commented that they were looking forward to future workshops of similar design. Participants also stated that they felt more confident performing nerve blocks and looked forward to applying these skills in the clinical setting.

Discussion

A focused small-group workshop directed towards developing the confidence and skill set necessary to perform UGRNBs can be successfully offered to emergency medicine residents in a single-day workshop.

Topics

Ultrasound, nerve block, local anesthesia, injection, pain, resident, workshop.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study

OBJECTIVE

Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake.

DESIGN

This is a retrospective review from 2015 to 2018.

PATIENTS

Nonsyndromic patients undergoing primary palate repair.

MAIN OUTCOMES MEASURES

Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered.

RESULTS

Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05).

CONCLUSION

Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

BACKGROUND

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

METHODS

After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R², scaled Brier score, and calibration slope.

RESULTS

The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R² 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041).

CONCLUSIONS

We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.

CLINICAL TRIAL REGISTRATION

NCT05018104.

Implementation and Postoperative Management of Continuous Adductor Canal Catheters for Total Knee Arthroplasty to Reduce Surgical Backlog Related to the COVID-19 Pandemic: An Acute Pain Service Nursing Perspective and Educational Resource

PURPOSE

In response to the surgical backlog created by the COVID-19 pandemic and to spare valuable hospital resources, we developed and implemented a continuous adductor canal catheter (CACC) program for total knee arthroplasty (TKA) patients. CACC's offer superior analgesia, decrease opioid use, and increase patient satisfaction while simultaneously promoting a decreased length of hospital stay and even same day discharges. The implementation of analgesia protocols using continuous peripheral nerve catheters and isometric pumps has been described for other surgical procedures and populations; however, the role of the Acute Pain Service Nurse (APS RN) in the implementation of such a program has not been described.

DESIGN

An best practice initiative for TKA patients receiving CACC was developed and implemented for patients recovering both in the hospital and at home.

METHODS

We describe the development and implementation of a CACC program for TKA patients in response to the surgical backlog created by the COVID-19 pandemic from the perspective of the APS RN. We provide a detailed narrative description of our postoperative assessment and experience, and offer practical insights for the postoperative care of these patients. We share the educational resources and assessment tools we developed to ensure consistent, safe, and effective clinical management of CACC patients in the hospital and at home.

FINDINGS

CACCs via elastomeric pumps have been shown to offer significant advances to pain control following TKA, decrease opioid use, enable earlier discharge, and improve patient satisfaction, all of which we observed unequivocally in our patients. In our experience, implementation of a daily telephone follow up by an APS RN for discharged TKA patients with a CACC was crucial for patient safety, patient satisfaction, and reducing emergency phone calls and emergency room visits.

CONCLUSIONS

We anticipate this description will provide an invaluable educational resource for other Acute Pain Service programs as similar outpatient peripheral nerve catheter programs are developed in response to the pandemic.

Erector Spinae Plane Blocks With Liposomal Bupivacaine for Pediatric Scoliosis Surgery

Pain management in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion can be challenging. Various analgesic techniques are currently used, including enhanced recovery after surgery principles, spinal opioids or continuous epidural infusion, intravenous methadone, or surgical site infiltration of local anesthetic. Another recently developed technique, ultrasound-guided erector spinae plane blockade (ESPB), has been used successfully in spine surgery and may offer advantages because of its ease of placement, excellent safety profile, and opioid sparing qualities. Liposomal bupivacaine is a long-acting local anesthetic that was recently approved for infiltration and fascial plane blocks in pediatric patients of ages 6 years and older. This medication may prove to be beneficial when administered through ESPB in patients with AIS undergoing posterior spinal fusion because it can provide prolonged analgesia after a single injection. Here, we present a case report of two such patients, and we compare outcomes with a retrospective cohort of 13 patients with AIS who received IV methadone instead of ESPB. ESPB patients seemed to have less opioid use and shorter length of stay but higher pain scores, although the sample size is too small for meaningful statistical analysis. Future prospective trials are needed to see if differences in outcomes truly exist.

Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery

Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis

BACKGROUND

Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures.

OBJECTIVE

We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department.

METHODS

Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome.

RESULTS

Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I² = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay.

CONCLUSIONS

FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

Local Infiltrative Analgesia is Equivalent to Fascia Iliaca Block for Perioperative Pain Management for Prophylactic Cephalomedullary Nail Fixation

BACKGROUND

Impending pathologic fractures of the femur due to metastatic bone disease are treated with prophylactic internal fixation to prevent fracture, maintain independence, and improve quality of life. There is limited data to support an optimal perioperative pain regimen.

METHODS

A proof of concept comparative cohort analysis was performed: 21 patients who received a preoperative fascia iliacus nerve block (FIB) were analyzed retrospectively while 9 patients treated with local infiltrative analgesia (LIA) were analyzed prospectively. Primary outcomes included: visual analog scale (VAS) pain scores, narcotic requirements and hospital length of stay. Patient cohorts were compared via two-sample t-tests and Fischer's exact tests. Differences in VAS pain scores, length of stay and morphine milligram equivalents (MME) were assessed with Wilcoxon rank sum.

RESULTS

The LIA group had more patients treated with preoperative narcotics (p=0.042). There were no significant differences between the FIB and LIA groups in MME utilized intraoperatively (30.0 vs 37.5, p=0.79), on POD 0 (38.0 vs 30.0, p=0.93), POD 1 (46.0 vs 55.5, p=0.95) or POD 2 (40.0 vs 60.0 p=0.73). There were no significant differences in analog pain scale at any time point or in hospital length of stay (78 vs 102 hours, p=0.86).

CONCLUSION

Despite an increased number of patients being on preoperative narcotics in the LIA group, use of LIA compared with FIB is not associated with an increase in VAS pain scores, morphine milligram equivalents (MME), or length of hospital stay in patients undergoing prophylactic internal fixation of impending pathologic femur fractures.Level of Evidence: III.

Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial

Introduction & aim: Temporary (60-day) percutaneous peripheral nerve stimulation (PNS) has demonstrated effectiveness for the treatment of chronic post-amputation pain, and this pilot study aims to evaluate the feasibility of temporary percutaneous PNS for the treatment of acute post-amputation pain. Patients & methods: Sixteen veterans undergoing lower extremity amputation received PNS and standard medical therapy or standard medical therapy alone. Results: The PNS group reported greater reductions in average phantom limb pain, residual limb pain and daily opioid consumption, and there were fewer participants taking opioids through 3 months post-amputation. Conclusion: This pilot study suggests that PNS is feasible in the acute postoperative period following lower limb amputation and may provide a non-pharmacologic analgesic therapy that lowers pain scores and reduces opioid consumption, and thus warrants further investigation.