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Vallejo MC, Kumaraswami S, Zakowski MI. American Society of Anesthesiologists 2023 Guidance on Neurologic Complications of Neuraxial Analgesia/Anesthesia in Obstetrics. Anesthesiology 2024; 140:1235-1236. [PMID: 38578973 DOI: 10.1097/aln.0000000000004967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
| | | | - Mark I Zakowski
- Cedars-Sinai Medical Center, Los Angeles, California (M.I.Z.).
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2
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Neely G, Hollis N, Mozingo C. Anesthesia for the Patient Undergoing Knee Procedures. Anesthesiol Clin 2024; 42:247-261. [PMID: 38705674 DOI: 10.1016/j.anclin.2023.11.016] [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] [Indexed: 05/07/2024]
Abstract
Anesthesia for patients undergoing knee procedures encompasses a large patient population with significant variation in patient age, comorbidities, and type of surgery. In addition, these procedures are performed in vastly different surgical environments, including large academic hospitals, private hospitals, and out-patient surgical centers. These variabilities require a thoughtful and individualized anesthetic approach tailored toward the medical and surgical needs of each patient. This article discusses anesthetic approaches to patients with acute, subacute, and chronic knee-related pathology requiring surgery. We will also review pertinent knee anatomy and innervation and discuss regional nerve blocks and their applications to knee-related surgical procedures.
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Affiliation(s)
- Grant Neely
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA.
| | - Nicole Hollis
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
| | - Cy Mozingo
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
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Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Anesthesiol Clin 2024; 42:329-344. [PMID: 38705680 DOI: 10.1016/j.anclin.2023.11.013] [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] [Indexed: 05/07/2024]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
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Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
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Potvin CA, Ip VHY. Regional Anesthesia for Athletes Undergoing Upper Extremity Procedures: Techniques and Considerations. Anesthesiol Clin 2024; 42:203-217. [PMID: 38705671 DOI: 10.1016/j.anclin.2023.11.006] [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] [Indexed: 05/07/2024]
Abstract
Upper extremity injuries are frequent in athletes which may require surgeries. Regional anesthesia for postoperative analgesia is important to aid recovery, and peripheral nerve blocks for surgical anesthesia enable surgeries to be performed without general anesthetics and their associated adverse effects. The relevant nerve block approaches to anesthetize the brachial plexus for elbow, wrist and hand surgeries are discussed in this article. There is very limited margin for error when performing nerve blocks and multimodal monitoring approach to reduce harm are outlined. Lastly, the importance of obtaining informed consent prior to nerve block procedures should not be overlooked.
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Affiliation(s)
- Carole-Anne Potvin
- CHU de Québec - Enfant- Jésus & Saint-Sacrement, 1050 Ch Ste-Foy, Québec, QC, G1S 4L8, Canada
| | - Vivian H Y Ip
- Department of Anesthesia and Pain Medicine, University of Alberta Hospital, 2-150 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
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Fountoulaki M, Kapetanakis EI, Kouna N, Papagiannis N, Sidiropoulou T. Hemodynamic instability caused by pneumorrachis and pneumomediastinum following epidural analgesia: a case report. J Med Case Rep 2024; 18:263. [PMID: 38807243 PMCID: PMC11134872 DOI: 10.1186/s13256-024-04588-y] [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: 03/09/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. CASE PRESENTATION We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. CONCLUSION Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.
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Affiliation(s)
- Maria Fountoulaki
- Second Department of Anesthesiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece.
| | - Niki Kouna
- Second Department of Anesthesiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece
| | - Nikolaos Papagiannis
- Second Department of Radiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece
| | - Tatiana Sidiropoulou
- Second Department of Anesthesiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece
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Bais K, Guirguis F, Guirguis M. Nerve Injury Following Regional Nerve Block: A Literature Review of Its Etiologies, Risk Factors, and Prevention. Curr Pain Headache Rep 2024:10.1007/s11916-024-01268-w. [PMID: 38807008 DOI: 10.1007/s11916-024-01268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Postoperative nerve injury after nerve block is complex and multifactorial. The mechanisms, etiologies, and risk factors are explored. This review article conducts a literature search and summarizes current evidence and best practices in prevention of nerve injury. RECENT FINDINGS Emerging technology such as ultrasound, injection pressure monitors, and nerve stimulators for peripheral nerve block have been incorporated into regular practice to reduce the rate of nerve injury. Studies show avoidance of intrafascicular injection, limiting concentrations/volumes of local anesthetic, and appropriate patient selection are the most significant controllable factors in limiting the negative consequences of nerve block. Peripheral nerve injury is an uncommon occurrence after nerve block and is obscured by surgical manipulation, positioning, and underlying neural integrity. Underlying neural integrity is not always evident despite an adequate history and physical exam. Surgical stress, independently of nerve block, may exacerbate these neurologic disease processes and make diagnosing a postoperative nerve injury more challenging. Prevention of nerve injury by surgical teams, care with positioning, and avoidance of intrafascicular injection with nerve block are the most evidence-based practices.
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Affiliation(s)
- Kimmy Bais
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Fady Guirguis
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mina Guirguis
- University of Texas at Southwestern Medical Center, Dallas, TX, USA
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Kim NE, Lee WJ, Jung JK, Song JH, Joa KL, Yang CW, Jung EC, Jo SM, Ko YS. Diabetic Neuropathy and Minimum Effective Anesthetic Concentration of Mepivacaine for Axillary Brachial Plexus Block: A Prospective Observational Study. J Pers Med 2024; 14:353. [PMID: 38672980 PMCID: PMC11051194 DOI: 10.3390/jpm14040353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Nerves in patients with diabetic neuropathy (DN) show increased susceptibility to local anesthetics, potentially requiring a decreased dose. We investigated whether the minimum effective anesthetic concentration (MEAC) of mepivacaine for successful axillary block is lower in patients with DN than in those without. This prospective observational study included patients with DN (n = 22) and without diabetes (n = 22) at a tertiary care center. Patients received an ultrasound-guided axillary block with 30 mL of mepivacaine for anesthesia. The mepivacaine concentration used in each patient was calculated using Dixon's up-and-down method. A block was considered successful if all four sensory nerves had a score of 1 or 2 within 30 min with no pain during surgery. The primary outcome was the MEAC of mepivacaine, and the secondary outcomes included the minimal nerve stimulation intensity for the musculocutaneous nerve and the occurrence of adverse events. The MEAC50 was 0.55% (95% CI 0.33-0.77%) in patients without diabetes and 0.58% (95% CI 0.39-0.77%) in patients with DN (p = 0.837). The MEAC90 was 0.98% (95% CI 0.54-1.42%) in patients without diabetes and 0.96% (95% CI 0.57-1.35%) in patients with DN (p = 0.949). The stimulation threshold for the musculocutaneous nerve was significantly different between groups (0.49 mA vs. 0.19 mA for patients with vs. without diabetes; p = 0.002). In conclusion, the MEAC of mepivacaine for a successful axillary block is not lower in patients with DN.
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Affiliation(s)
- Na-Eun Kim
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Woo-Joo Lee
- The Department of Public Health Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Republic of Korea;
| | - Jong-Kwon Jung
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Jang-Ho Song
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Kyung-Lim Joa
- The Department of Physical and Rehabilitation Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea;
| | - Chun-Woo Yang
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Eui-Chan Jung
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Soo-Man Jo
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
| | - Yeong-Seung Ko
- The Department of Anesthesiology and Pain Medicine, School of Medicine, Inha University, 100 Inha-ro, Michuhol-gu, Incheon 22212, Republic of Korea; (N.-E.K.); (J.-K.J.); (J.-H.S.); (E.-C.J.); (S.-M.J.); (Y.-S.K.)
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Howe D, Hulgur M. A survey about the practice of regional anesthesia in Manchester and Lancashire. Pain Pract 2024; 24:404-408. [PMID: 37864326 DOI: 10.1111/papr.13311] [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: 10/22/2023]
Abstract
INTRODUCTION In 2021, the UK Royal College of Anaesthetists published an updated curriculum which outlines specific peripheral nerve blocks in which all anesthetists must achieve competency during their training. Little is known about which nerve blocks anesthetists in the UK can perform, nor which techniques they use to perform them. METHODS We conducted a survey of anesthetists in North West England to discover their experience in anesthesia, which nerve blocks they can perform, and which techniques they use to perform them. RESULTS Overall, 195 responses were received. Seventy-nine respondents (44%) preferred to perform nerve blocks on anesthetized patients, 70 (40%) preferred to perform nerve blocks with the patient awake with no sedation. One hundred and thirty-seven (85%) respondents used ultrasound only to localize nerves when performing a block. Among consultant respondents, 21 (19%) were unable to perform any upper limb block, and 48 (44%) were unable to perform any block of the thorax, both are a required competency of trainees under the 2021 curriculum. DISCUSSION Trainees may struggle to achieve the required competencies of the new curriculum given many consultants are also unable to perform them. A structured placement in regional anesthetic training in each stage of training could help improve the acquisition of skills and knowledge among trainees. Further studies are needed to assess the ability of anesthetists nationwide in regional anesthesia.
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Affiliation(s)
- David Howe
- Department of Anesthesia, Stepping Hill Hospital, Manchester, UK
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Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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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: 0] [Impact Index Per Article: 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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Soeding P, Morris A, Soeding A, Hoy G. Effect of intravenous magnesium on post-operative pain following Latarjet shoulder reconstruction. Shoulder Elbow 2024; 16:46-52. [PMID: 38435030 PMCID: PMC10902413 DOI: 10.1177/17585732231158805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 01/24/2023] [Accepted: 02/04/2023] [Indexed: 03/05/2024]
Abstract
Background Single injection ropivacaine interscalene anesthesia (ISA) is frequently used in Latarjet reconstruction to enhance post-operative analgesia. A potential limitation is the occurrence of severe rebound pain on block resolution. We investigated the effect of intravenous magnesium on post-operative pain, particularly at the transition of block resolution to multimodal analgesia. Methods Elective patients (n = 40) having Latarjet open shoulder reconstruction were randomised to receive either intravenous magnesium sulphate 50 mg/kg (M) or normal saline (S) before induction. Post-operatively, a standardised analgesic regimen was used, and post-operative pain was recorded using a verbal numerical rating assessment (VNRA) score. Requirement for injected opioid analgesia was recorded. Results ISA provided longstanding analgesia in all patients with block duration slightly prolonged in the magnesium group (16.7(1.0) (S), 17.8(1.3) h (M), p = 0.049). Magnesium resulted in less rebound pain following ISA resolution (VNRA 4.0 (0.6) M, 6.2 (0.8) S, p = 0.03) and lower pain intensity at 24 h. Four patients had nausea and two required rescue opioid injection. Conclusion Magnesium before Latarjet surgery results in less rebound pain following ropivacaine block and improves post-operative analgesia. Magnesium may be indicated in major upper limb surgery, where significant pain intensity is anticipated. Level of evidence Treatment study; Randomised blinded; Level 2.
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Affiliation(s)
- Paul Soeding
- FANZCA Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, Australia
- Department of Pharmacology and Therapeutics, The University of Melbourne, Victoria, Australia
| | - Alex Morris
- The University of Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Adam Soeding
- Department of Preventative Medicine, The Alfred Centre Monash University, Prahran, Australia
| | - Gregory Hoy
- Melbourne Orthopaedic Group, Monash University Department of Surgery, Windsor, Australia
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12
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Litz RJ, Feigl GC, Radny D, Weiß T, Schwarzkopf P, Mäcken T. Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:233. [PMID: 38399521 PMCID: PMC10890524 DOI: 10.3390/medicina60020233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/20/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.
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Affiliation(s)
| | - Georg C. Feigl
- Institute of Anatomy, University of Witten/Herdecke, 58455 Witten, Germany;
| | - Daniel Radny
- Department of Anaesthesiology and Intensive Care Medicine, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany;
| | - Thomas Weiß
- Department of Anesthesia and Intensive Care Medicine, Thurgau Cantonal Hospital, 8596 Münsterlingen, Switzerland;
| | - Peter Schwarzkopf
- Clinic for Anesthesiology, Intensive Care, Palliative and Pain Medicine, Sana Hospital Leipziger Land, 04552 Borna, Germany;
| | - Tim Mäcken
- Department of Anaesthesiology, Intensive Care and Pain Medicine, BG University Hospital Bergmannsheil, 44789 Bochum, Germany
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Singh N, Pritzlaff S, Bautista B, Yan C, Wilson MD, Chang J, Fishman SM. Correlation between epidural space depth measured with ultrasound and MRI compared to clinical loss of resistance when performing lumbar epidural steroid injection. Reg Anesth Pain Med 2024:rapm-2023-105135. [PMID: 38267075 DOI: 10.1136/rapm-2023-105135] [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: 10/30/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND This prospective study assessed the accuracy of MRI and ultrasound (US) measurements as a preprocedural assessment tool for predicting clinical loss of resistance depth (CLORD) during fluoroscopy-guided lumbar epidural steroid injections (ESIs). MATERIALS AND METHODS Sixty patients enrolled received lumbar ESIs at an academic chronic pain clinic. The MRI measurement calculated the distance between the skin and the posterior epidural space, while US measurements included transverse and parasagittal oblique views of the interlaminar space. The epidural space measurements were compared with the CLORD during the performance of the prone epidural injections. The differences in measurements were analyzed using two one-sided tests for equivalency with a 0.5 equivalency margin. The intraclass correlation coefficients between CLORD and the imaging modalities were estimated using mixed effects models. RESULTS MRI was equivalent to CLORD with a mean difference of -0.2 cm (95% CI -0.39 to -0.11). US transverse and US parasagittal oblique measurements were not equivalent to and underestimated CLORD with mean differences of -0.98 cm (90% CI -1.8 to -0.77) and -0.79 cm (90% CI -1.0 to -5.9), respectively. The intraclass correlation coefficients between MRI and CLORD were the highest at 0.85, compared with 0.65 and 0.73 for transverse and parasagittal oblique US views, respectively. CONCLUSIONS MRI measurements are preferable over US for preprocedural assessment of patients receiving lumbar ESIs for predicting CLORD.
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Affiliation(s)
- Naileshni Singh
- Department of Anesthesiolgy and Pain Medicine, University of California Davis, Sacramento, California, USA
| | - Scott Pritzlaff
- Department of Anesthesiolgy and Pain Medicine, University of California Davis, Sacramento, California, USA
| | - Barry Bautista
- School of Medicine, University of California Davis, Sacramento, California, USA
| | - Charley Yan
- School of Medicine, University of California Davis, Sacramento, California, USA
| | - Machelle D Wilson
- Public Health Sciences, Division of Biostatistics, University of California Davis, School of Medicine, Sacramento, California, USA
| | - Jennifer Chang
- Department of Radiology, University of California San Diego, La Jolla, California, USA
| | - Scott M Fishman
- Department of Anesthesiolgy and Pain Medicine, University of California Davis, Sacramento, California, USA
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14
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Avellanal M, Riquelme I, Ferreiro A, Boezaart A, Reina MA. Neuraxial pathology and regional anesthesia: an education guide to decision-making. Reg Anesth Pain Med 2024:rapm-2023-105106. [PMID: 38253611 DOI: 10.1136/rapm-2023-105106] [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: 10/22/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
In current clinical practice, spinal anesthesia and analgesia techniques-including epidural and subarachnoid procedures-are frequently executed without imaging like X-ray or epidurography. Unrecognized spinal pathology has resulted in serious morbidity in the context of performing neuraxial anesthesia. Typically, preoperative consultations incorporate a patient's medical history but lack a detailed spinal examination or consideration of recent MRI or CT scans. In contrast, within the domain of pain clinics, a multidisciplinary approach involving anesthesiologists and neuroradiologists is common. Such collaborative settings rely on exhaustive clinical history and scrutinization of recent imaging studies, which may influence the decision to proceed with invasive spinal interventions. There are no epidemiological data concerning rates of the different baseline pathologies that would potentially pose morbidity risks from neuraxial procedures, but the most common among these is canal stenosis, which significantly affects almost 20% of people over 60 years of age. This paper aims to elucidate these critical findings and advocate for incorporating meticulous preoperative assessments for individuals slated for spinal anesthesia or analgesia procedures, thereby attempting to mitigate potential risks.
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Affiliation(s)
| | - Irene Riquelme
- Pain Clinic, Hospital Universitario La Moraleja, Madrid, Spain
| | - Antonio Ferreiro
- Universidad San Pablo CEU, Madrid, Spain
- Radiology, Hospital Universitario de Madrid, Madrid, Spain
| | - Andre Boezaart
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
- Lumina Health, Sarrey, UK
| | - Miguel Angel Reina
- Department of Anesthesiology, CEU San Pablo University Faculty of Medicine, Madrid, Spain
- University of Florida College of Medicine, Gainesville, Florida, USA
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15
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Scarpelli EM, Park CH, Jeng CL. Regional anesthesia and anticoagulation: a narrative review of current considerations. Int Anesthesiol Clin 2024; 62:1-9. [PMID: 38063032 DOI: 10.1097/aia.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Enrico M Scarpelli
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Christina L Jeng
- Department of Anesthesiology, Perioperative and Pain Medicine; Orthopaedics; and Medical Education, Mount Sinai Hospital, New York, New York
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16
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Ghafoor H, Haroon S, Atique S, Ul Huda A, Ahmed O, Bel Khair AOM, Abdus Samad A. Neurological Complications of Local Anesthesia in Dentistry: A Review. Cureus 2023; 15:e50790. [PMID: 38239523 PMCID: PMC10796083 DOI: 10.7759/cureus.50790] [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: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
Local anesthesia is a technique that temporarily desensitizes a specific body area, typically for a surgical procedure, dental work, or pain management. It is described as a sensation loss in a specific area of the body due to depression of excitation in the nerve endings or due to the inhibition of the conduction process within the peripheral nerves. It allows for safer and more comfortable medical procedures, reducing the need for general anesthesia and facilitating faster recovery. Local anesthesia is generally safe, but like any medical intervention, it carries potential risks and side effects. The complications related to local anesthetics can be assessed in terms of neurological, vascular, local, systemic, and neurological. In this review article, we discussed the neurological complications of local anesthesia related to the ophthalmic nerve, maxillary nerve, mandibular nerve, branches of the trigeminal nerve, and facial nerve. These include diplopia, ptosis, paralysis of the eye, blindness, paresthesia, trismus, soft tissue lesions, edema, hematoma, facial blanching, infection, allergy, overdose, neuralgia, facial palsy, etc.
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Affiliation(s)
- Hashsaam Ghafoor
- Department of Anesthesia, Hamad Medical Corporation, Al Khor, QAT
- Department of Anesthesia, Qatar University, Doha, QAT
| | - Saad Haroon
- Department of Endodontics, Primary Health Care Corporation, Doha, QAT
| | - Sundus Atique
- College of Dental Medicine, QU Health, Qatar University, Doha, QAT
| | - Anwar Ul Huda
- Department Of Anesthesia, Hamad Medical Corporation, Doha, QAT
| | - Osman Ahmed
- College of Medicine, Qatar University, Doha, QAT
- Department of Anesthesia, Al Khor Hospital, Hamad Medical Corporation, Al Khor, QAT
| | | | - Aijaz Abdus Samad
- Department of Anesthesia and ICU, Latifa Women and Children Hospital, Dubai, ARE
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17
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Frost S, Rodrigues D, Amadeo RJJ, Wolfe S, Funk F, Ferguson C, Brown H, MacDonald P, Dufault B, Mutter TC. Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data. Reg Anesth Pain Med 2023; 48:553-560. [PMID: 37295793 DOI: 10.1136/rapm-2022-104086] [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: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Postoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled trial participants. METHODS Data were pooled from two randomized controlled trials of analgesia after interscalene block with perineural or intravenous adjuvants (NCT02426736, NCT03270033). Participants were at least 18 years of age and undergoing arthroscopic shoulder surgery at a single ambulatory surgical center. PONS were assessed by telephone follow-up at 14 days and 6 months postoperatively, and defined as patient report of numbness, weakness, or tingling in the surgical limb, alone or in combination, and regardless of severity or etiology. RESULTS At 14 days, PONS occurred in 83 of 477 patients (17.4%). Among these 83 patients, 10 (12.0%) continued to have symptoms a half-year after surgery. In exploratory univariate analyses, no patient, surgical or anesthetic characteristics were significantly associated with 14-day PONS except for lower postoperative day 1 Quality of Recovery-15 questionnaire total score (OR 0.97 (95% CI, 0.96 to 0.99), p<0.01). This result was driven largely by the emotional domain question scores (OR 0.90 95% CI 0.85 to 0.96, p<0.001). Report of all three of numbness, weakness and tingling at 14 days vs other 14-day symptom combinations was associated with persistent PONS at 6 months (OR 11.5 95% CI 2.2 to 61.8, p<0.01). CONCLUSION PONS are common after arthroscopic shoulder surgery performed with single injection ultrasound-guided interscalene blocks. No definitive mitigating risk factors were identified.
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Affiliation(s)
- Samantha Frost
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Daniel Rodrigues
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Ryan J J Amadeo
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Scott Wolfe
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Faylene Funk
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Celeste Ferguson
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Holly Brown
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Peter MacDonald
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Brenden Dufault
- George and Fay Yee Centre for Health Care Innovation, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Thomas Charles Mutter
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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18
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Hsieh YL, Chen HY, Lin CR, Wang CF. Efficacy of epidural analgesia for intractable cancer pain: A systematic review. Pain Pract 2023; 23:956-969. [PMID: 37455298 DOI: 10.1111/papr.13273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Epidural analgesia is a common technique for managing perioperative and obstetric pain. Patients with cancer who cannot tolerate opioids or not responding to conventional treatment may benefit from epidural analgesia. Therefore, this systematic review aimed to analyze the efficacy and safety of epidural analgesia in patients with intractable cancer pain. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify studies on patients with cancer who received epidural analgesia. We assessed the quality of all included studies using the risk-of-bias tool or Newcastle-Ottawa scale. The primary outcome was pain relief after epidural analgesia, and the secondary outcome was quality of life, analgesic consumption, and adverse events. The studies were grouped based on the medications used for epidural analgesia. A descriptive synthesis was performed following the Synthesis Without Meta-analysis reporting guideline. RESULTS Our systematic review included nine randomized controlled trials (n = 340) and 15 observational studies (n = 926). Two randomized controlled trials suggested that epidural opioids were not superior to systemic opioids in relieving pain. Epidural opioids combined with local anesthetics or adjuvants, including calcitonin, clonidine, ketamine, neostigmine, methadone, and dexamethasone, offered better analgesic effects. No significant difference in pain relief between an intermittent bolus and a continuous infusion of epidural morphine was observed. Epidural opioids had more analgesic effects on nociceptive pain than neuropathic pain. The methods used to evaluate the quality of life and the corresponding results were heterogeneous among studies. Six observational studies demonstrated that some patients could have decreased opioid consumption after epidural analgesia. Adverse events, including complications and drug-related side effects, were reported in 23 studies. Five serious complications, such as epidural abscess and hematoma, required surgical management. The heterogeneity and methodological limitations of the studies hindered meta-analysis and evidence-level determination. CONCLUSION Coadministration of epidural opioids, local anesthetics, and adjuvants may provide better pain relief for intractable cancer pain. However, we must assess the patients to ensure that the benefits outweigh the risks before epidural analgesia. Therefore, further high-quality studies are required.
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Affiliation(s)
- Yu-Lien Hsieh
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Yu Chen
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Ren Lin
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Fei Wang
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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19
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McLeod GA, Cowie A, Sadler A, Watson F, Wasik P, Reina MA. Accuracy of injection pressure measurement at peripheral nerves using high-resolution 40 MHz ultrasound in an anesthetized porcine model. Reg Anesth Pain Med 2023; 48:501-507. [PMID: 36822816 DOI: 10.1136/rapm-2022-104282] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Fluid injection pressure measurement is promoted as a marker of needle tip position that discriminates between tissue layers. However, clinical ultrasound has insufficient resolution to identify the exact position of the needle tip. Our primary objective was to use 40 MHz ultrasound in anesthetized pigs in order to precisely locate the tip of the needle and measure opening injection pressure in muscle, at epineurium and in subepineurium. METHODS We surgically exposed the axillae of four anesthetized pigs. Two operators placed a 40 MHz ultrasound transducer over the pectoral muscle and imaged axillary, median and radial nerves. Injections (0.5 mL) were randomized to in-plane and out-of-plane needle trajectories and flow rates of 1, 6 and 12 mL/min. RESULTS We identified 541 fascicles in 23 nerves. The ratio of fascicle area to nerve area remained constant at ~0.30 for all nerves. Axillary nerves were smaller than median and radial nerves, difference in diameter (95% CI) 1.61 (0.87 to 2.36) mm, p<0.001 and 1.59 (0.82 to 2.36) mm, p=0.001, respectively. Axillary nerves had less fascicles per nerve than median nerves, difference 7.63 (2.43 to 12.83) and radial nerves, difference 9.02 (3.64 to 14.40). We visualized the circumneurium and injection within the subcircumneural compartment. Intraneural injection increased nerve area (SD) from 5.7 (2.2) mm2 to 13.7 (5.5) mm2, difference 8.0 (5.4-10.6) mm2, p<0.001. Mean injection pressure was greater in subepineurium compared with muscle, geometric ratio 2.29 (1.30 to 4.10), p<0.001; and greater on epineurium compared with muscle, geometric ratio 1.73 (1.03 to 3.00), p=0.01. Twenty-two out of 23 injections in muscle, 14 out of 23 injections at epineurium and 11 out of 22 injections in subepineurium were <138 kPa (20 psi). CONCLUSION Needle tip position was not discernible using pressure monitoring. The circumneurium and subcircumneural injection compartment were observed but not intrafascicular injection.
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Affiliation(s)
- Graeme A McLeod
- Department of Anaesthesia, Ninewells Hospital, Dundee, UK
- Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | | | - Amy Sadler
- Department of Anaesthesia, NHS Tayside, Dundee, UK
| | - Fiona Watson
- Department of Anaesthesia, NHS Tayside, Dundee, UK
| | - Paul Wasik
- Department of Anaesthesia, NHS Tayside, Dundee, UK
| | - Miguel Angel Reina
- Department of Anesthesiology, CEU San Pablo University Faculty of Medicine, Madrid, Spain
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20
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Koh K, Tatsuki O, Sakuraba S, Yamazaki S, Yako H, Omae T. Neuropathies Following an Ultrasound-Guided Axillary Brachial Plexus Block. Local Reg Anesth 2023; 16:123-132. [PMID: 37693952 PMCID: PMC10488563 DOI: 10.2147/lra.s426515] [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: 07/11/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose Ultrasound-guided brachial plexus block (UGBPB) has interscalene, supraclavicular, infraclavicular, and axillary approaches. The axillary block is considered to be the safest and with fewer adverse events compared to the interscalene (eg, phrenic nerve block, spinal cord or vertebral artery puncture) and supraclavicular (eg, pneumothorax). However, with regard to postoperative neurological symptoms (PONS), it is controversial whether its incidence after an axillary block was higher than that after non-axillary approaches". In this study, we investigated whether the incidence of a neuropathy after an axillary block was higher than that after non-axillary approaches. Patients and Methods This was a single-center, retrospective cohort study. All UGBPBs were performed under general anesthesia between January 2014 and March 2020. The outcomes included the overall incidence of PONS and neuropathies for axillary and non-axillary approaches. The etiology, symptoms, and outcomes of patients were investigated. Results Of the 992 patients, 143 (14%) and 849 (86%) were subjected to axillary and non-axillary approaches, respectively. Among 19 cases (19.2:1000; 95% confidence interval [CI], 18.2-20.1) of PONS, four (4.0:1000; 95% CI, 3.8-4.2) were neuropathies attributed to the UGBPB, three (21.0:1000; 95% CI, 18.1-23.8) to the axillary and one (2.8:1000; 95% CI, 2.6-3.1) to non-axillary approaches. The incidence of neuropathies after an axillary block was significantly higher than that after non-axillary approaches (P = 0.005). Conclusion The incidence of neuropathies after US-guided axillary block under general anesthesia was significantly higher than that after non-axillary approaches.
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Affiliation(s)
- Keito Koh
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Onishi Tatsuki
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sonoko Sakuraba
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sho Yamazaki
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hajime Yako
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Takeshi Omae
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
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21
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Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, Van Zundert J. 2. Cervical radicular pain. Pain Pract 2023; 23:800-817. [PMID: 37272250 DOI: 10.1111/papr.13252] [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] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both. METHODS The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized. RESULTS The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered. CONCLUSIONS There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Brigitte Brouwer
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rathmell James
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Leroy D. Vandam Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre Wolff
- Department of Anesthesiology, UMCG Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
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22
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Sonawane K, Dixit H, Thota N, Mistry T, Balavenkatasubramanian J. "Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part B (Nerve Injury Types, Mechanisms, and Pathogenesis). Cureus 2023; 15:e43143. [PMID: 37692583 PMCID: PMC10484240 DOI: 10.7759/cureus.43143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Selander emphatically said, "Handle these nerves with care," and those words still echo, conveying a loud and clear message that, however rare, peripheral nerve injury (PNI) remains a perturbing possibility that cannot be ignored. The unprecedented nerve injuries associated with peripheral nerve blocks (PNBs) can be most tormenting for the unfortunate patient and a nightmare for the anesthetist. Possible justifications for the seemingly infrequent occurrences of PNB-related PNIs include a lack of documentation/reporting, improper aftercare, or associated legal implications. Although they make up only a small portion of medicolegal claims, they are sometimes difficult to defend. The most common allegations are attributed to insufficient informed consent; preventable damage to a nerve(s); delay in diagnosis, referral, or treatment; misdiagnosis, and inappropriate treatment and follow-up care. Also, sufficient prospective studies or randomized trials have not been conducted, as exploring such nerve injuries (PNB-related) in living patients or volunteers may be impractical or unethical. Understanding the pathophysiology of various types of nerve injury is vital to dealing with them further. Processes like degeneration, regeneration, remyelination, and reinnervation can influence the findings of electrophysiological studies. Events occurring in such a process and their impact during the assessment determine the prognosis and the need for further interventions. This educational review describes various types of PNB-related nerve injuries and their associated pathophysiology.
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Affiliation(s)
- Kartik Sonawane
- Anesthesiology, Ganga Medical Centre and Hospitals, Coimbatore, IND
| | - Hrudini Dixit
- Anesthesiology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, IND
| | - Navya Thota
- Anesthesiology, Ganga Medical Centre and Hospitals, Coimbatore, IND
| | - Tuhin Mistry
- Anesthesiology, Ganga Medical Centre and Hospitals, Coimbatore, IND
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23
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McLennan L, Haines M, Graham D, Sullivan T, Lawson R, Sivakumar B. Regional Anesthesia in Upper-Limb Surgery. Ann Plast Surg 2023; 91:187-193. [PMID: 37450877 DOI: 10.1097/sap.0000000000003592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant. METHODS A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia. RESULTS Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings. CONCLUSIONS This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.
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Affiliation(s)
| | - Morgan Haines
- Plastic and Reconstructive Surgery, Royal North Shore Hospital, Sydney
| | - David Graham
- Gold Coast University Hospital, Gold Coast, Australia
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24
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Sonawane K, Dixit H, Mehta K, Thota N, Gurumoorthi P. "Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part C (Prevention of Nerve Injuries). Cureus 2023; 15:e41847. [PMID: 37581128 PMCID: PMC10423097 DOI: 10.7759/cureus.41847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/16/2023] Open
Abstract
"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.
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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
| | - Kaveri Mehta
- Anesthesia and Critical Care, Corniche Hospital, Abu Dhabi, ARE
| | - Navya Thota
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
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25
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Shermon S, Van Acker G, Suric V, Kim C, Abd-Elsayed A, Mata N. Flushing After Lumbar Epidural Steroid Injection with Dexamethasone. Curr Pain Headache Rep 2023; 27:143-148. [PMID: 37115487 DOI: 10.1007/s11916-023-01117-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE OF REVIEW Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%). RECENT FINDINGS There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.
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Affiliation(s)
- Suzanne Shermon
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Gustaf Van Acker
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Vladimir Suric
- Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chong Kim
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
| | - Nicholas Mata
- Physical Medicine and Rehabilitation, All Star Pain Management, Annapolis, MD, USA
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Illescas A, Zhong H, Liu J, Cozowicz C, Poeran J, Memtsoudis SG. Neuraxial Use Among Total Knee and Hip Arthroplasty Patients With Multiple Sclerosis or Myasthenia Gravis. Anesth Analg 2023; 136:1182-1188. [PMID: 36939157 DOI: 10.1213/ane.0000000000006471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
BACKGROUND Surgical patients with preexisting neurological diseases create greater challenges to perioperative management, and choice of anesthetic is often complicated. We investigated neuraxial anesthesia use in total knee and hip arthroplasty (TKA/THA) recipients with multiple sclerosis or myasthenia gravis compared to the general population. METHODS We retrospectively analyzed patients undergoing a TKA/THA with a diagnosis of multiple sclerosis or myasthenia gravis (Premier Health Database, 2006-2019). The primary outcome was neuraxial anesthesia use in multiple sclerosis or myasthenia gravis patients compared to the general population. Secondary outcomes were length of stay, intensive care unit admission, and mechanical ventilation. We measured the association between the aforementioned subgroups and neuraxial anesthesia use. Subsequently, subgroup-specific associations between neuraxial anesthesia and secondary outcomes were measured. We report odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Among 2,184,193 TKA/THAs, 7559 and 3176 had a multiple sclerosis or myasthenia gravis diagnosis, respectively. Compared to the general population, neuraxial anesthesia use was lower in multiple sclerosis patients (OR, 0.61; CI, 0.57-0.65; P < .0001) and no different in myasthenia gravis patients (OR, 1.05; CI, 0.96-1.14; P = .304). Multiple sclerosis patients administered neuraxial anesthesia (compared to those without neuraxial anesthesia) had lower odds of prolonged length of stay (OR, 0.63; CI, 0.53-0.76; P < .0001) mirroring neuraxial anesthesia benefits seen in the general population. CONCLUSIONS Neuraxial anesthesia use was lower in surgical patients with multiple sclerosis compared to the general population but no different in those with myasthenia gravis. Neuraxial use was associated with lower odds of prolonged length of stay.
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Affiliation(s)
- Alex Illescas
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Haoyan Zhong
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
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27
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Yin J, Yin W, Kairis E, Thomas S, Montoya M, Orebaugh S. Neurologic outcomes with peripheral nerve blockade in distal upper extremity nerve trauma: a retrospective study. Reg Anesth Pain Med 2023; 48:141-143. [PMID: 35944935 DOI: 10.1136/rapm-2022-103734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/02/2022] [Indexed: 01/31/2023]
Affiliation(s)
- John Yin
- Department of Anesthesiology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Wu Yin
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Kairis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Shavin Thomas
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Mario Montoya
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Steven Orebaugh
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
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28
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Kaushik P, Hayaran N, Goel I. Multimodal Approach in Minimizing Transient Neurological Complications Following Single Shot Brachial Plexus Block: A Prospective Observational Study. Cureus 2023; 15:e35667. [PMID: 36875251 PMCID: PMC9978168 DOI: 10.7759/cureus.35667] [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: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
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.
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Affiliation(s)
- Parul Kaushik
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Nitin Hayaran
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Ishan Goel
- Radiology, Lady Hardinge Medical College, New Delhi, IND
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29
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Bottomley T, Gadsden J, West S. The failed peripheral nerve block. BJA Educ 2023; 23:92-100. [PMID: 36844443 PMCID: PMC9947978 DOI: 10.1016/j.bjae.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/21/2023] Open
Affiliation(s)
- T. Bottomley
- University College London NHS Foundation Trust, London, UK
| | - J. Gadsden
- Duke University Medical Centre, Durham, NC, USA
| | - S. West
- University College London NHS Foundation Trust, London, UK
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Vieira I, Cunha P, Pinto M, Ribeiro S, Sacramento S, Silva A, Almeida C, Guedes I. Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:224-230. [PMID: 36842688 DOI: 10.1016/j.redare.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/30/2022] [Indexed: 02/28/2023]
Abstract
BACKGROUND Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce. METHODS A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane. RESULTS Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies. CONCLUSION Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.
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Affiliation(s)
- I Vieira
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal.
| | - P Cunha
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - M Pinto
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - S Ribeiro
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - S Sacramento
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - A Silva
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - C Almeida
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - I Guedes
- Department of Anaesthesiology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
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Van Roekel NL, Deliberato DG, Bayers-Thering M, Phillips MJ. Superficial Femoral Artery Pseudoaneurysm After Intra-articular Adductor Canal Pain Catheter Placement for Total Knee Arthroplasty. Orthopedics 2023; 46:e58-e61. [PMID: 36476287 DOI: 10.3928/01477447-20221129-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Vascular injury following total knee arthroplasty (TKA) is a rare complication. The authors present a case of superficial femoral artery aneurysm in a 60-year-old man following elective TKA in the setting of intra-articular On-Q* (Avanos Medical) pain catheter placement into the adductor canal for postoperative pain control. This is the second reported case of pseudoaneurysm secondary to adductor canal block. The patient presented on postoperative day 8 with thigh swelling, ecchymosis, and pain. The pseudoaneurysm was subsequently diagnosed and successfully stented after selective catheterization. The patient was discharged the next day. This case highlights the importance for a high index of suspicion in patients presenting with acute swelling in the postoperative period. If identified in a timely fashion, treatment with stenting or selective catheter embolization can successfully treat this issue and help avoid further complications. [Orthopedics. 2023;46(1):e58-e61.].
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Rugg CM, Ginder JH, Bharadwaj A, Vomer R, Dale GA, Ketterly J, Zarzour H, Amendola A, Lau BC. Perioperative Management in the Collegiate Athlete: An Integrated Approach. Sports Med Int Open 2023; 7:E1-E8. [PMID: 37101550 PMCID: PMC10125641 DOI: 10.1055/a-2051-7756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/26/2023] [Indexed: 04/28/2023] Open
Abstract
Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.
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Affiliation(s)
| | | | | | - Rock Vomer
- Orthopedics, Division of Sports Medicine, Duke University, Durham,
United States
- Correspondence Dr. Rock Vomer Duke
UniversityOrthopedics, Division of Sports
Medicine3475 Erwin
Road27708–0187
DurhamUnited States919 668n
1400
| | | | | | - Hap Zarzour
- Athletics, Duke University, Durham, United States
| | | | - Brian C. Lau
- Orthopedics, Duke University, Durham, United States
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Tonks KE, Birch S, Ito Y, Bhagwat A. Perioperative management of a parturient with VACTERL association for a caesarean section. Anaesth Rep 2023; 11:e12213. [PMID: 36798639 PMCID: PMC9925372 DOI: 10.1002/anr3.12213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/15/2023] Open
Abstract
A parturient with VACTERL association (vertebral defects, anal atresia, cardiac defects, trachea-oesophageal fistula, renal abnormalities and limb abnormalities) was listed for an elective caesarean section. She had a short neck with reduced cervical extension and flexion. Magnetic resonance imaging of her whole spine was performed which showed failure of cervical spine segmentation and cervical stenosis. Neuraxial blockade could have resulted in unpredictable spread of local anaesthetic due to the low volume of the spinal canal, and could have caused myelopathic changes within the spinal cord due to cerebrospinal fluid pressure changes. A general anaesthetic using a rapid sequence induction was also predicted to be challenging due to her fixed, unstable neck and severe cervical spine stenosis. After a multidisciplinary discussion Including neurosurgeons, we planned for awake tracheal intubation followed by general anaesthesia. However, before the date of her planned delivery, she required an urgent caesarean section due to severe preeclampsia. This was performed under general anaesthesia following uncomplicated awake tracheal intubation.
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Affiliation(s)
- K. E. Tonks
- Department of AnaesthesiaUniversity Hospitals of North Midlands NHS TrustStoke‐on‐TrentUK
| | - S. Birch
- Department of AnaesthesiaUniversity Hospitals of North Midlands NHS TrustStoke‐on‐TrentUK
| | - Y. Ito
- Department of AnaesthesiaRoyal Wolverhampton TrustWolverhamptonUK
| | - A. Bhagwat
- Department of AnaesthesiaUniversity Hospitals of North Midlands NHS TrustStoke‐on‐TrentUK
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Crutchfield CR, Schweppe EA, Padaki AS, Steinl GK, Roller BA, Brown AR, Lynch TS. A Practical Guide to Lower Extremity Nerve Blocks for the Sports Medicine Surgeon. Am J Sports Med 2023; 51:279-297. [PMID: 35437023 DOI: 10.1177/03635465211051757] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) are vital in the administration of surgical analgesia and have grown in popularity for use in lower extremity arthroscopic procedures because of their capacity to safely and effectively control pain. The number and specificity of PNBs, however, have made choosing the best option for a procedure nebulous for orthopaedic surgeons. PURPOSE To present a narrative literature review of the PNBs available for arthroscopic hip and knee procedures that is adapted to an audience of orthopaedic surgeons. STUDY DESIGN Narrative literature review. METHODS A combination of the names of various lower extremity PNBs AND "hip arthroscopy" OR "knee arthroscopy" was used to search the English medical literature including PubMed, Cochrane Library, ScienceDirect, Embase, and Scopus. Placement technique, specificity of blockade, efficacy, and complications were assessed. Searches were performed through May 2, 2021. RESULTS A total of 157 studies were included in this review of lower extremity PNBs. Femoral nerve, lumbar plexus, sciatic nerve, and fascia iliaca compartment blocks were most commonly used in arthroscopic hip surgery, while femoral nerve, 3-in-1, and adductor canal blocks were preferred for arthroscopic knee surgery. Each block demonstrated a significant benefit (P > .05) in ≥1 of the following outcomes: intraoperative morphine, pain scores, nausea, and/or opioid consumption. Combination blocks including the lateral femoral cutaneous nerve block, obturator nerve block, quadratus lumborum block, and L1 and L2 paravertebral block have also been described. Complication rates ranged from 0% to 4.8% in those administered with ultrasound guidance. The most commonly reported complications included muscular weakness, postoperative falls, neuropathy, intravascular and intraneural injections, and hematomas. CONCLUSION When administered properly, PNBs were a safe and effective adjuvant method of pain control with a significant potential to limit postoperative narcotic use. While blockade choice varies by surgeon preference and procedure, all PNBs should be administered with ultrasound guidance, and vigilant protocols for the risk of postoperative falls should be exercised in patients who receive them.
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Affiliation(s)
| | - Eric A Schweppe
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ajay S Padaki
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Brian A Roller
- Columbia University Irving Medical Center, New York, New York, USA
| | - Anthony R Brown
- Columbia University Irving Medical Center, New York, New York, USA
| | - T Sean Lynch
- Columbia University Irving Medical Center, New York, New York, USA
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Albaum JM, Abdallah FW, Ahmed MM, Siddiqui U, Brull R. What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials. Clin Orthop Relat Res 2022; 480:2374-2389. [PMID: 36083846 PMCID: PMC10538904 DOI: 10.1097/corr.0000000000002367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of neurologic symptoms after regional anesthesia in orthopaedic surgery is estimated to approach 3%, with long-term deficits affecting 2 to 4 per 10,000 patients. However, current estimates are derived from large retrospective or observational studies that are subject to important systemic biases. Therefore, to harness the highest quality data and overcome the challenge of small numbers of participants in individual randomized trials, we undertook this systematic review and meta-analysis of contemporary randomized trials. QUESTIONS/PURPOSES In this systematic review and meta-analysis of randomized trials we asked: (1) What is the aggregate pessimistic and optimistic risk of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery? (2) What block locations have the highest and lowest risk of postoperative neurologic symptoms? (3) What is the timing of occurrence of postoperative neurologic symptoms (in days) after surgery? METHODS We searched Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Web of Science, Scopus, and PubMed for randomized controlled trials (RCTs) published between 2008 and 2019 that prospectively evaluated postoperative neurologic symptoms after peripheral nerve blocks in operative procedures. Based on the Grading of Recommendations, Assessment, Development, and Evaluation guidance for using the Risk of Bias in Non-Randomized Studies of Interventions tool, most trials registered a global rating of a low-to-intermediate risk of bias. A total of 12,532 participants in 143 trials were analyzed. Data were pooled and interpreted using two approaches to calculate the aggregate risk of postoperative neurologic symptoms: first according to the occurrence of each neurologic symptom, such that all reported symptoms were considered mutually exclusive (pessimistic estimate), and second according to the occurrence of any neurologic symptom for each participant, such that all reported symptoms were considered mutually inclusive (optimistic estimate). RESULTS At any time postoperatively, the aggregate pessimistic and optimistic risks of postoperative neurologic symptoms were 7% (915 of 12,532 [95% CI 7% to 8%]) and 6% (775 of 12,532 [95% CI 6% to 7%]), respectively. Interscalene block was associated with the highest risk (13% [661 of 5101] [95% CI 12% to 14%]) and axillary block the lowest (3% [88 of 3026] [95% CI 2% to 4%]). Of all symptom occurrences, 73% (724 of 998) were reported between 0 and 7 days, 24% (243 of 998) between 7 and 90 days, and 3% (30 of 998) between 90 and 180 days. Among the 31 occurrences reported at 90 days or beyond, all involved sensory deficits and four involved motor deficits, three of which ultimately resolved. CONCLUSION When assessed prospectively in randomized trials, the aggregate risk of postoperative neurologic symptoms associated with peripheral nerve block in upper extremity surgery was approximately 7%, which is greater than previous estimates described in large retrospective and observational trials. Most occurrences were reported within the first week and were associated with an interscalene block. Few occurrences were reported after 90 days, and they primarily involved sensory deficits. Although these findings cannot inform causation, they can help inform risk discussions and clinical decisions, as well as bolster our understanding of the evolution of postoperative neurologic symptoms after regional anesthesia in upper extremity surgery. Future prospective trials examining the risks of neurologic symptoms should aim to standardize descriptions of symptoms, timing of evaluation, classification of severity, and diagnostic methods. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Jordan M. Albaum
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Faraj W. Abdallah
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
| | - M. Muneeb Ahmed
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Urooj Siddiqui
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Mount Sinai Hospital, Toronto, ON, Canada
| | - Richard Brull
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, ON, Canada
- Department of Anesthesia, Women’s College Hospital and Toronto Western Hospital, Toronto, ON, Canada
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Abstract
Appropriate perioperative pain control is essential to aid in patients' recovery after surgery; however, acute postsurgical pain remains poorly treated and there continues to be an overreliance on opiates. Perioperative pain control starts in the operating room, and opiate-free anesthesia (OFA), where no opiates are used intraoperatively, has been proposed as a feasible strategy to further minimize opiates in the perioperative period. In this article, we address the potential benefits and shortcomings of OFA, while exploring tools available to accomplish multimodal anesthesia and ideally OFA, and the evidence behind the techniques proposed.
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Brenna CTA, Khan S, Katznelson R, Brull R. The role of hyperbaric oxygen therapy in the management of perioperative peripheral nerve injury: a scoping review of the literature. Reg Anesth Pain Med 2022:rapm-2022-104113. [PMID: 36418044 DOI: 10.1136/rapm-2022-104113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
Background/importancePeripheral nerve injury is an uncommon but potentially catastrophic complication of anesthesia and surgery, for which there are limited effective treatment options. Hyperbaric oxygen therapy is a unique medical intervention which improves tissue oxygen delivery and reduces ischemia via exposure to oxygen at supra-atmospheric partial pressures. While the application of hyperbaric oxygen therapy has been evidenced for other medical conditions involving relative tissue ischemia, its role in the management of peripheral nerve injury remains unclear.ObjectiveThis scoping review seeks to characterize rehabilitative outcomes when hyperbaric oxygen therapy is applied as an adjunct therapy in the treatment of perioperative peripheral nerve injury.Evidence reviewThe review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines for scoping reviews, using a systematic screening and extraction process. The search included articles published from database inception until June 11, 2022, which reported clinical outcomes (in both human and non-human models) of peripheral nerve injury treated with hyperbaric oxygen therapy.FindingsA total of 51 studies were included in the narrative synthesis. These consisted of animal (40) and human studies (11) treating peripheral nerve injury due to various physiological insults. Hyperbaric oxygen therapy protocols were highly heterogenous and applied at both early and late intervals relative to the time of peripheral nerve injury. Overall, hyperbaric oxygen therapy was reported as beneficial in 88% (45/51) of included studies (82% of human studies and 90% of animal studies), improving nerve regeneration and/or time to recovery with no reported major adverse events.ConclusionsExisting data suggest that hyperbaric oxygen therapy is a promising intervention in the management of perioperative peripheral nerve injury, in which tissue ischemia is the most common underlying mechanism of injury, neurological deficits are severe, and treatment options are sparse. This positive signal should be further investigated in prospective randomized clinical trials.
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Gerner P, Cozowicz C, Memtsoudis SG. Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice? Anesthesiol Clin 2022; 40:433-444. [PMID: 36049872 DOI: 10.1016/j.anclin.2022.04.001] [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] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Philipp Gerner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02143, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria.
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Standard of anesthesia care: possible dissociation from recommendations made by clinical practice guidelines. J Anesth 2022; 36:642-647. [PMID: 35997835 DOI: 10.1007/s00540-022-03098-9] [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: 03/25/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
A medical malpractice lawsuit may be brought against health care providers, if there was a possibility of a negligence, or failure to meet the standard of care. Recently, clinical practice guidelines have increasingly been used as evidence of the standard of care. Nevertheless, it is not clear whether these guidelines can be used as evidence of the standard of care. We carried out a snapshot study to know whether or not there were dissociations between the current standard of anesthesia care and recommendations made by clinical practice guidelines. We asked all the 80 heads of Anesthesiology departments of Japanese public and private Universities, to answer questions related to difficult airway management after induction of anesthesia, postoperative monitoring of breathing, and of the presence or the absence of neuropathy of the lower legs after regional anesthesia. The response rate was 71% (57/80). The majority of anesthesiologists had little experience with front-of-neck access in patient, and responders might frequently make repeated attempts at tracheal intubation. Postoperative monitoring was frequently not routinely performed. In conclusion, this study has shown that there may be various degrees of dissociations between the current standard of anesthesia care and the recommendations made by clinical practice guidelines that had been used as evidence of the standard of care in medical malpractice lawsuit cases in Japan.
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Baranidharan G, Bretherton B, Black S. A case series of new radicular pain following the insertion of spinal cord stimulator. Br J Pain 2022; 16:450-457. [PMID: 36032340 PMCID: PMC9411753 DOI: 10.1177/20494637221084187] [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: 08/03/2023] Open
Abstract
Purpose Although spinal cord stimulation (SCS) is a safe procedure, equipment-related, biological and neurological complications have been observed in previous research, particularly case reports. No reports of new neuropathic pain in the absence of neurological deficit or positive MRI findings have been described. We detail three cases of new-onset radicular pain in the L5/S1 dermatome following insertion of SCS. Methods This was a retrospective case series of three patients. Details of clinical background, indications for SCS and events occurring during insertion and further management were recorded. Results All three cases were technically difficult and required multiple epidural entry levels, with repeated passage of the electrode into and within the epidural space. All cases involved accessing epidural space T12/L1 and L1/L2. A possible explanation for the new-onset radicular pain could concern oedema to the conus medullaris, resulting from repeated passage of the electrode at the T12/L1 level. Alternative explanations could be direct trauma to transiting nerve roots, neuroplastic changes resulting in peripheral and central sensitisation and immune-mediated nerve injury. Conclusion MRI imaging should be analysed prior to the SCS procedure to identify the level of the conus medullaris, with the aim of avoiding repeated passage of electrodes at that level. Unintended neurological adverse events should be discussed with patients during the consent process. Careful patient selection and psychological screening may also help identify patients who may be unlikely to respond to SCS therapy. Further reporting of new radiculopathic pain following SCS insertion is required to strengthen understanding of its potential causes.
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Affiliation(s)
- Ganesan Baranidharan
- Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, UK
| | - Beatrice Bretherton
- Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Faculty of Biological Sciences, School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Sheila Black
- Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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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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McClain RL, Rubin DI, Bais KS, Navarro AM, Robards CB, Porter SB. Regional anesthesia in patients with Charcot-Marie-Tooth disease: a historical cohort study of 53 patients. Can J Anaesth 2022; 69:880-884. [PMID: 35469042 DOI: 10.1007/s12630-022-02258-5] [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: 06/04/2021] [Revised: 01/02/2022] [Accepted: 01/26/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Anesthetic management for patients with Charcot-Marie-Tooth disease (CMT) is controversial. Description of the use of regional anesthesia (RA) in patients with CMT is limited. Regional anesthesia has traditionally been avoided because of risk of nerve injury. We retrospectively reviewed patients with CMT who received RA at our institution. METHODS We performed a historical cohort study of all patients with CMT who received RA from 30 April 2010 to 30 April 2020 within our institution. Charts were reviewed for information on demographics, RA procedures, perioperative variables, evidence of neurologic complications, post-RA neurology consults, and perioperative electromyography (EMG) results. Electromyographs were reviewed by a neurologist who was blinded to the surgical and RA details. RESULTS Fifty-three patients received a total of 132 regional anesthetics during the study period. Twenty-five patients received RA on more than one occasion. Fifty-five EMGs and 14 postoperative neurology consults were performed. Two patients had neurology consults with peripheral nerve block (PNB) distribution complaints years later. Neither attributed the complaints to the PNB. The other neurology consults were for unrelated complaints. No EMG results suggested injury related to PNB. CONCLUSION This study found no evidence of documented neurologic complications or an increased risk of nerve injury related to RA in CMT patients.
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Affiliation(s)
- Robert L McClain
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Devon I Rubin
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Kimmy S Bais
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Antonio M Navarro
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Christopher B Robards
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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Peripheral Nerve Injury After Upper-Extremity Surgery Performed Under Regional Anesthesia: A Systematic Review. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:201-207. [PMID: 35880155 PMCID: PMC9308165 DOI: 10.1016/j.jhsg.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Peripheral nerve injury (PNI) is a known adverse event following upper-limb surgery performed under brachial plexus regional anesthesia (RA). When PNI is noted after surgery, patients and providers often have questions about which factors might have contributed to this complication. This systematic review evaluates the literature on hand and shoulder surgeries performed under ultrasound-guided, plexus RA to identify factors potentially associated with PNI, including the surgery location and block type. We hypothesized that shoulder surgery might be associated with an increased risk of PNI compared to hand surgery. Methods A systematic review of the relevant literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only prospective studies on the use of ultrasound-guided, preoperative, brachial plexus RA for hand or shoulder surgery on adult patients were included. Study groups were categorized according to surgery location and block type and compared across a number of factors via univariate and multivariate analyses. Results A total of 3,037 abstracts were screened; 192 full-text articles were independently reviewed by 2 of the authors; and 53 studies were included in the systematic review analysis. Following hand surgery, PNI was reported at an average rate of 1.35% ± 3.21% across 836 subjects in 40 study groups; after shoulder surgery, the average rate was 0.50% ± 1.57% across 3,383 subjects in 15 study groups. There was no statistically significant correlation between the incidence of PNI and surgery location (P =.70) or any of the most common approaches for brachial plexus anesthesia in the multivariate analysis. Conclusions This systematic review of over 50 articles on upper-limb surgery performed under RA shows no association between the incidence of PNI and the location of surgery or type of brachial plexus block. Type of study/level of evidence Diagnostic II.
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Karsenty C, Tubman VN, Joyce Liu CJ, Fasipe T, Wyatt KEK. Regional anesthesia for sickle cell disease vaso-occlusive crisis: A single-center case series. Pediatr Blood Cancer 2022; 69:e29695. [PMID: 35373913 PMCID: PMC9172213 DOI: 10.1002/pbc.29695] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 11/08/2022]
Abstract
Pain management is challenging for patients with sickle cell disease (SCD) who present in vaso-occlusive crisis (VOC). Opioid therapy is highly effective, nevertheless undesirable side effects can hinder their effectiveness. Regional anesthesia with deposition of perineural anesthetic offers nociceptive blockade, local vasodilatation, and reduces the inflammatory response. Among pediatric patients, continuous peripheral nerve block (CPNB) for perioperative adjunctive analgesia is safe. Herein, we describe the trajectory of a cohort of pediatric SCD patients with opioid-refractory upper-extremity VOC following placement of CPNBs for analgesia; highlighting reduced opioid consumption, improved pain scores, and decreased length of hospitalization.
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Affiliation(s)
- Cecile Karsenty
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, 6701 Fannin St, Suite 1510, Houston, TX 77030,Department of Pediatrics, Baylor College of Medicine, Houston, TX, One Baylor Plaza, Houston, TX 77030
| | - Venee N. Tubman
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, 6701 Fannin St, Suite 1510, Houston, TX 77030
| | - Chyong-jy Joyce Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, 6621 Fannin St, Suite A3300, Houston, TX 77030,Department of Anesthesiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
| | - Titilope Fasipe
- Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, 6701 Fannin St, Suite 1510, Houston, TX 77030
| | - Karla E. K. Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, 6621 Fannin St, Suite A3300, Houston, TX 77030,Department of Anesthesiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
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Mutter T, Logan GS, Neily S, Richardson S, Askin N, Monterola M, Abou-Setta A. Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review. Can J Anaesth 2022; 69:736-749. [PMID: 35289378 DOI: 10.1007/s12630-022-02229-w] [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: 10/14/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB. METHODS Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery. RESULTS Fifty-five studies totalling 6,236 participants (median, 69; range, 30-910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences. CONCLUSION These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB. STUDY REGISTRATION PROSPERO (CRD42020148496); registered 10 February 2020.
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Affiliation(s)
- Thomas Mutter
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Gabrielle S Logan
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam Neily
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Scott Richardson
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Askin
- Neil John Maclean Health Sciences Library, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Marita Monterola
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ahmed Abou-Setta
- George and Fay Yee Centre for Healthcare Innovation, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Queiroz RD, Borger RA, Heitzmann LG, Fingerhut DJP, Saito LH. Fraturas intracapsulares do colo femoral no idoso. Rev Bras Ortop 2022; 57:360-368. [PMID: 35785116 PMCID: PMC9246523 DOI: 10.1055/s-0041-1736473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022] Open
Abstract
Currently, intracapsular femoral neck fracture (IFNF) is still a great challenge for orthopedists. In spite of the progress that has been made, a high mortality rate persists in the first year, especially in Brazil, where there is no awareness that such fractures in elderly patients should be treated as a medical emergency. The present article seeks to provide an update on the preoperative, surgical, and postoperative approaches.
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Affiliation(s)
- Roberto Dantas Queiroz
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Richard Armelin Borger
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Lourenço Galizia Heitzmann
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - David Jeronimo Peres Fingerhut
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
| | - Luiz Henrique Saito
- Serviço de Ortopedia e Traumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual (Iamspe), São Paulo, SP, Brasil
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Phrenic Nerve Block and Respiratory Effort in Pigs and Critically Ill Patients with Acute Lung Injury. Anesthesiology 2022; 136:763-778. [PMID: 35348581 DOI: 10.1097/aln.0000000000004161] [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
BACKGROUND Strong spontaneous inspiratory efforts can be difficult to control and prohibit protective mechanical ventilation. Instead of using deep sedation and neuromuscular blockade, the authors hypothesized that perineural administration of lidocaine around the phrenic nerve would reduce tidal volume (VT) and peak transpulmonary pressure in spontaneously breathing patients with acute respiratory distress syndrome. METHODS An established animal model of acute respiratory distress syndrome with six female pigs was used in a proof-of-concept study. The authors then evaluated this technique in nine mechanically ventilated patients under pressure support exhibiting driving pressure greater than 15 cm H2O or VT greater than 10 ml/kg of predicted body weight. Esophageal and transpulmonary pressures, electrical activity of the diaphragm, and electrical impedance tomography were measured in pigs and patients. Ultrasound imaging and a nerve stimulator were used to identify the phrenic nerve, and perineural lidocaine was administered sequentially around the left and right phrenic nerves. RESULTS Results are presented as median [interquartile range, 25th to 75th percentiles]. In pigs, VT decreased from 7.4 ml/kg [7.2 to 8.4] to 5.9 ml/kg [5.5 to 6.6] (P < 0.001), as did peak transpulmonary pressure (25.8 cm H2O [20.2 to 27.2] to 17.7 cm H2O [13.8 to 18.8]; P < 0.001) and driving pressure (28.7 cm H2O [20.4 to 30.8] to 19.4 cm H2O [15.2 to 22.9]; P < 0.001). Ventilation in the most dependent part decreased from 29.3% [26.4 to 29.5] to 20.1% [15.3 to 20.8] (P < 0.001). In patients, VT decreased (8.2 ml/ kg [7.9 to 11.1] to 6.0 ml/ kg [5.7 to 6.7]; P < 0.001), as did driving pressure (24.7 cm H2O [20.4 to 34.5] to 18.4 cm H2O [16.8 to 20.7]; P < 0.001). Esophageal pressure, peak transpulmonary pressure, and electrical activity of the diaphragm also decreased. Dependent ventilation only slightly decreased from 11.5% [8.5 to 12.6] to 7.9% [5.3 to 8.6] (P = 0.005). Respiratory rate did not vary. Variables recovered 1 to 12.7 h [6.7 to 13.7] after phrenic nerve block. CONCLUSIONS Phrenic nerve block is feasible, lasts around 12 h, and reduces VT and driving pressure without changing respiratory rate in patients under assisted ventilation. EDITOR’S PERSPECTIVE
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Vakos A, Dean K, Reeder C, Louis-Jacques A. Management of cauda equina syndrome during pregnancy and postpartum. BMJ Case Rep 2022; 15:e238793. [PMID: 35487643 PMCID: PMC9058678 DOI: 10.1136/bcr-2020-238793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 01/27/2023] Open
Abstract
Cauda equina syndrome (CES) is a rare condition that occurs from multiple nerve root compression. It is considered a surgical emergency because it can lead to permanent neurological damage. There is limited literature regarding management and prognosis of CES for pregnant patients, leaving providers with many questions when encountering patients with this condition. We describe the case of a patient who developed CES during pregnancy. She presented at 30 weeks gestation and successfully underwent surgical decompression in prone position. She later delivered via elective caesarean at term. This case highlights management considerations for pregnant patients with CES, including positioning during surgery and use of regional anaesthesia.
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Affiliation(s)
- Amanda Vakos
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Kathryn Dean
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Callie Reeder
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
| | - Adetola Louis-Jacques
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
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An T, Schwartz E, Kissen M, Pollock G, Pfeffer G. Safety and Efficacy of Postoperative Indwelling Popliteal Nerve Catheters for Outpatient Charcot-Marie-Tooth Surgery. Foot Ankle Int 2022; 43:504-508. [PMID: 34889125 DOI: 10.1177/10711007211060038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Outpatient surgical deformity correction for Charcot-Marie-Tooth (CMT) disease is limited by effective postoperative pain control. Our previous institutional protocol for foot and ankle surgery in this population included preoperative single-injection nerve blocks, but patients often experienced uncontrolled pain when the block wore off postoperative day 0 or 1, resulting in high opioid requirements and unplanned emergency department visits. The use of ultrasonography-guided continuous nerve catheters in CMT patients has not previously been studied. We aimed to prospectively investigate the safety and efficacy of ultrasonography-guided indwelling popliteal catheters in CMT patients undergoing outpatient foot deformity correction surgery. METHODS Twenty CMT patients, average 28 (range 13-53) years old, undergoing reconstructive surgery by a single foot and ankle attending surgeon were consented for preoperative ultrasonography-guided popliteal catheters. This series included 24 total outpatient procedures; 4 were staged bilateral. Indwelling popliteal catheters were maintained on discharge, providing continuous infusion until postoperative day (POD) 3, and then self-discontinued. Patients were prescribed oxycodone 5 mg (60-80 pills) as needed for breakthrough pain. Outcomes collected included daily pain scores (0-10), an opioid pill count on POD 14, and patient satisfaction ratings. Neurologic evaluation by 5-point 10g Semmes-Weinstein monofilament testing was performed preoperatively and on POD 14. RESULTS There were no observed catheter-site infections or hematomas. Nine of the patients had pre-existing sensory deficits involving at least 2 areas on the 5-point monofilament test. Postoperative testing showed these deficits were unchanged and there were no instances of new sensory deficits. Postoperative pain scores were typically low, with median values (interquartile ranges [IQRs]) of 3.5 (2.0-5.0) on POD 1, 2.5 (2.0-5.0) on POD 2, and 2.5 (1.0-3.75) on POD 3. At POD 14, pain was 1.0 (0-1.0). Patients consumed a median of 25 oxycodone pills (IQR 8-43) over 2 weeks, less than half the prescribed number. Patient satisfaction was high. All patients reported they would choose to have a nerve catheter again for a similar surgery. CONCLUSION This cases series demonstrated that regional anesthesia using ultrasonography-guided indwelling popliteal catheters was safe and effective for pain control in CMT patients undergoing outpatient foot and ankle surgery. Opioid consumption was comparable to published rates following major bony procedures, and no patients required emergent treatment or hospital admission for uncontrolled pain. No new sensory deficits were detected and patients with underlying sensory deficits remained unchanged. Patients were highly satisfied. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Tonya An
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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50
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Neely G, Hollis N, Mozingo C. Anesthesia for the Patient Undergoing Knee Procedures. Clin Sports Med 2022; 41:247-261. [PMID: 35300838 DOI: 10.1016/j.csm.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Anesthesia for patients undergoing knee procedures encompasses a large patient population with significant variation in patient age, comorbidities, and type of surgery. In addition, these procedures are performed in vastly different surgical environments, including large academic hospitals, private hospitals, and out-patient surgical centers. These variabilities require a thoughtful and individualized anesthetic approach tailored toward the medical and surgical needs of each patient. This article discusses anesthetic approaches to patients with acute, subacute, and chronic knee-related pathology requiring surgery. We will also review pertinent knee anatomy and innervation and discuss regional nerve blocks and their applications to knee-related surgical procedures.
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Affiliation(s)
- Grant Neely
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA.
| | - Nicole Hollis
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
| | - Cy Mozingo
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
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