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Meyer P, Schroeder K. Regional Anesthesia in the Elite Athlete. Anesthesiol Clin 2024; 42:291-302. [PMID: 38705677 DOI: 10.1016/j.anclin.2023.11.010] [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
Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.
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Affiliation(s)
- Patrick Meyer
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Kristopher Schroeder
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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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: 6] [Impact Index Per Article: 6.0] [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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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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Abstract
Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.
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Affiliation(s)
- Patrick Meyer
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Kristopher Schroeder
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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Coudray A, Choquet O, Swisser F, Hochman M, Bringuier S, Capdevila X. Combination of real-time needle-tip pressure sensing and minimal intensity stimulation limits unintentional intraneural injection during an ultrasound-guided peripheral nerve block procedure: A randomized, parallel group, controlled trial. J Clin Anesth 2021; 74:110420. [PMID: 34171709 DOI: 10.1016/j.jclinane.2021.110420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/03/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Ultrasound guidance does not eliminate the risk of intraneural injection, which must be avoided during PNB. Combining ultrasound guidance (USG), nerve stimulation (NS), and injection pressure monitoring is advocated to prevent nerve injury during PNB. We hypothesized that combining patient-tailored dynamic NS and real-time pressure sensing (RTPS) could reduce the incidence of intraneural injection and nerve puncture during USG PNB compared with a traditional fixed thresholds (Control) procedure. DESIGN Randomized, prospective study. SETTING Operating room. PATIENTS One hundred ASA physical status I to III patients undergoing orthopedic surgery. INTERVENTIONS Patient anesthetized using axillary, sciatic or femoral USG PNB were randomized to the PresStim group (Dynamic RTPS and NS set at 1.5 mA then decreased; n = 50) or Control group (fixed thresholds for in-line pressure mechanical manometer and NS at 0.2 mA; n = 50). MEASUREMENTS Procedural ultrasound images and videos were recorded, stored and reviewed in random order by two experts in ultrasound-guided PNB blinded to the group. They noted the needle-to-nerve relationship and intraneural injection for all blocked nerves. MAIN RESULTS One hundred and twenty-three USG PNBs were performed (56 axillary brachial plexus blocks, 40 femoral nerve blocks and 27 sciatic popliteal nerve blocks); 235 blocked nerves and videos were recorded and analyzed (PresStim, 118; Control, 117). Less paresthesia was noted in the PresStim group (12.7%) compared with the Control group (18.8%). The risk of intraneural injection was significantly higher in the Control group (odds ratio [OR], 17.1; 95% confidence interval [CI], 2.2-135, P = 0.007). The risk of nerve puncture (OR, 22.7; 95% CI, 2.9-175, p = 0.003) and needle-nerve contact (OR, 4.7; 95% CI, 2.4-9.5, p < 0.001) was significantly higher in the Control group than the PresStim group. CONCLUSIONS Under the conditions of the study, dynamic triple monitoring combining RTPS, NS and USG decreases intraneural injection and unintentional needle-nerve contact and puncture during a PNB procedure.
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Affiliation(s)
- Adrien Coudray
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Olivier Choquet
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Fabien Swisser
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Mark Hochman
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Department of Restorative Dentistry, Stony Brook School of Dental Medicine, NY, New York, United States of America
| | - Sophie Bringuier
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Department of Medical Statistics, Montpellier University Hospital, 34295 Montpellier Cedex 5, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Inserm Unit 1051 Montpellier NeuroSciences Institute, Montpellier University, 34295 Montpellier Cedex 5, France.
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Mejia J, Varela V, Domenech J, Goffin P, Prats-Galino A, Sala-Blanch X. Opening injection pressure monitoring using an in-line device does not prevent intraneural injection in an isolated nerve model. Reg Anesth Pain Med 2021; 46:916-918. [PMID: 34155090 DOI: 10.1136/rapm-2021-102788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Injection pressure monitoring using in-line devices is affordable and easy to implement into a regional anesthesia practice. However, solid evidence regarding their performance is lacking. We aimed to evaluate if opening injection pressure (OIP), measured with a disposable in-line pressure monitor, can prevent intraneural (subepineural) injection using 15 pound per square inch (PSI) as the reference safety threshold. METHODS An isolated nerve model with six tibial and six common peroneal nerves from three unembalmed fresh cadavers was used for this observational study. A mixture of 0.5% ropivacaine with methylene blue was injected intraneurally at a rate of 10 mL/min, to a maximum of 3 mL. OIP was recorded for each injection as well as evidence of intraneural contrast. Injected volume at 15 and 20 PSI was recorded, and when it leaked out the epineurium, if it occurred. RESULTS In all cases, OIP was<15 PSI and intraneural contrast was evident before the safety threshold. The 15-20 PSI mark was attained in 5 of 12 injections (41%), with a median injected volume of 0.9 mL (range 0.4-2.3 mL). Peak pressure of >20 PSI was reached in two injections (at 0.6 mL and 2.7 mL). Contrast leaked out the epineurium in 11 of 12 injections (91%) with a median injected volume of 0.6 mL (range 0.1-1.3 mL). CONCLUSIONS Our results suggest that in-line pressure monitoring may not prevent intraneural injection using an injection pressure of 15 PSI as reference threshold. Due to the preliminary nature of our study, further evidence is needed to demonstrate clinical relevance.
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Affiliation(s)
- Jorge Mejia
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Victor Varela
- Master in Advanced Medical Skills in Regional Anesthesia based in Anatomy, University of Barcelona, Barcelona, Catalunya, Spain
| | - Javier Domenech
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Pierre Goffin
- Anesthesia and intensive care, MontLégia Hospital, Groupe Santé CHC, Liège, Belgium.,Masters Degree in Advanced Medical Competences, Regional Anaesthesia Based on Human Anatomy, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Alberto Prats-Galino
- Human Anatomy and Embryology, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain .,Anatomy and Embriology Department, Universitat of Barcelona, Barcelona, Spain
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McLeod G, Zihang S, Sadler A, Chandra A, Qiao P, Huang Z, Demore C. Validation of the soft-embalmed Thiel cadaver as a high-fidelity simulator of pressure during targeted nerve injection. Reg Anesth Pain Med 2021; 46:540-548. [PMID: 33906953 DOI: 10.1136/rapm-2020-102132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/24/2021] [Accepted: 03/30/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although administration of regional anesthesia nerve blocks has increased during the COVID-19 pandemic, training opportunities in regional anesthesia have reduced. Simulation training may enhance skills, but simulators must be accurate enough for trainees to engage in a realistic way-for example, detection of excessive injection pressure. The soft-embalmed Thiel cadaver is a life-like, durable simulator that is used for dedicated practice and mastery learning training in regional anesthesia. We hypothesized that injection opening pressure in perineural tissue, at epineurium and in subepineurium were similar to opening pressures measured in experimental animals, fresh frozen cadavers, glycol soft-fix cadavers and patients. METHODS We systematically reviewed historical data, then conducted three validation studies delivering a 0.5 mL hydrolocation bolus of embalming fluid and recording injection pressure. First, we delivered the bolus at 12 mL/min at epimysium, perineural tissue, epineurium and in subepineurium at 48 peripheral nerve sites on three cadavers. Second, we delivered the bolus at using three infusion rates: 1 mL/min, 6 mL/min and 12 mL/min on epineurium at 70 peripheral nerve sites on five cadavers. Third, we repeated three injections (12 mL/min) at 24 epineural sites over the median and sciatic nerves of three cadavers. RESULTS Mean (95%) injection pressure was greater at epineurium compared with subepineurium (geometric ratio 1.2 (95% CI: 0.9 to 1.6)), p=0.04, and perineural tissue (geometric ratio 5.1 (95% CI: 3.7 to 7.0)), p<0.0001. Mean (95%) injection pressure was greater at 12 mL/min compared with 1 mL/min (geometric ratio 1.6 (95% CI: 1.2 to 2.1), p=0.005). Pressure measurements were similar in study 3 (p>0.05 for all comparisons). DISCUSSION We conclude that the soft-embalmed Thiel cadaver is a realistic simulator of injection opening pressure.
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Affiliation(s)
- Graeme McLeod
- Department of Anaesthesia, Ninewells Hospital, Dundee, UK .,Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | - Shengli Zihang
- Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | - Amy Sadler
- Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, UK
| | - Anu Chandra
- Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | - Panpan Qiao
- Department of Bioengineering, University of Dundee, Dundee, UK
| | - Zhihong Huang
- Institute of Academic Anaesthesia, University of Dundee, Dundee, UK
| | - Christine Demore
- Department of BioPhysics, Sunnybrook Research Institute, Toronto, Ontario, Canada
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Needle insertion forces and fluid injection pressures during targeting of nerves in a soft embalmed cadaver model. J Clin Monit Comput 2021; 36:511-519. [PMID: 33704653 DOI: 10.1007/s10877-021-00680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Forceful needle-nerve contact and high subepineural pressures and are recognised causes of nerve damage. Pressure and force measurements are necessary to inform the mechanisms of nerve injury, build virtual simulator environments and provide operator feedback during simulation training. However, the range of pressures and forces encountered at tissue layers during targeted needle insertion and fluid injection are not known. METHODS We built a needle that recorded in-line pressure during fluid injection and continuously measured force at the needle tip. Two anaesthetists were randomised to insert a 21 g block needle at 48 nerve sites on both sides of 3 soft embalmed Thiel cadavers. Our objective was to measure pressure and force during the course of targeted nerve injection at epimysium, in perineural tissue, on epineurium and during subepineural injection. At each interface, we infused a 0.5 ml bolus of embalming solution at a rate of 12 ml min-1 and recorded the pressure response. Force was measured continuously in the background throughout the procedure. RESULTS Pressure was greater at epineurium and within subepineurium than perineural tissue, geometric ratio (95% CI) 4.7 (3.0-7.3) kPa and 3.8 (2.5-5.7) kPa, respectively, both P < 0.0001. Force on nerve contact and on nerve penetration was greater than force in perineural tissue, geometric ratios (95% CI) 3.0 (1.9-4.7) N and 3.6 (2.2-7.5) N, respectively, both P < 0.0001. On nerve contact, 1 in 6 insertions were ≥ 5 N CONCLUSIONS: Despite valid infusion pressures, anaesthetists exerted excessive force on nerves.
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Varobieff M, Choquet O, Swisser F, Coudray A, Menace C, Molinari N, Bringuier S, Capdevila X. Real-Time Injection Pressure Sensing and Minimal Intensity Stimulation Combination During Ultrasound-Guided Peripheral Nerve Blocks: An Exploratory Observational Trial. Anesth Analg 2021; 132:556-565. [PMID: 33323786 DOI: 10.1213/ane.0000000000005308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nerve damage can occur after peripheral nerve block (PNB). Ultrasound guidance does not eliminate the risk of intraneural injection or nerve injury. Combining nerve stimulation and injection pressure (IP) monitoring with ultrasound guidance has been suggested to optimize needle tip location in PNB. In this prospective observational study, we hypothesized that measured pairs of IP and minimum intensity of stimulation (MIS) might differentiate successive needle tip locations established by high-resolution ultrasound during PNB. METHODS For this exploratory study, 240 observations for 40 ultrasound-guided PNBs were studied in 28 patients scheduled for orthopedic surgery. During the progression of the needle to the nerve observed by ultrasonography, the IP was measured continuously using a computerized pressure-sensing device with a low flow rate of solution. Stimulation thresholds and electrical impedance were obtained by an impedance analyzer coupled to the nerve stimulator at 6 successive needle positions. The median (quartile) or mean (95% confidence interval [CI]) was reported. A mixed model analysis was used, and the sample was also explored using a classification and regression tree (CART) algorithm. RESULTS Specific combinations of IP and MIS were measured for subcutaneous, epimysium contact, intramuscular, nerve contact (231 mm Hg [203-259 mm Hg] and 1.70 mA [1.38-2.02 mA]), intraneural location (188 mm Hg [152-224 mm Hg] and 0.58 mA [0.46-0.70 mA]), and subparaneural location (47 mm Hg [41-53 mm Hg] and 1.35 mA [1.09-1.61 mA]). The CART algorithm shows that the optimal subparaneural needle tip position might be defined by the lowest pressure (<81.3 mm Hg) and MIS (<1.5 mA) cutoffs. CONCLUSIONS Our exploratory study evaluated concepts to generate hypotheses. The combinations of IP and MIS might help the physician during a PNB procedure. A low IP and low MIS might confirm a subparaneural location, and a high IP and a low MIS might be an alert for the intraneural location of the needle tip.
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Affiliation(s)
- Maxime Varobieff
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Olivier Choquet
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Fabien Swisser
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Adrien Coudray
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Cecilia Menace
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France
| | - Nicolas Molinari
- Department of Medical Statistics and Epidemiology, Montpellier University Hospital, Montpellier Cedex 5, France
| | - Sophie Bringuier
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France.,Department of Medical Statistics and Epidemiology, Montpellier University Hospital, Montpellier Cedex 5, France
| | - Xavier Capdevila
- From the Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier Cedex 5, France.,Institut National de la Santé et de Recherche Médicale (INSERM), Unit 1051, Montpellier NeuroSciences Institute, Montpellier University, Montpellier Cedex 5, France
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Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study. J Clin Med 2021; 10:jcm10040781. [PMID: 33669190 PMCID: PMC7919789 DOI: 10.3390/jcm10040781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/07/2021] [Accepted: 02/12/2021] [Indexed: 11/21/2022] Open
Abstract
Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings.
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McLeod GA. Novel approaches to needle tracking and visualisation. Anaesthesia 2021; 76 Suppl 1:160-170. [PMID: 33426657 DOI: 10.1111/anae.15232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 12/22/2022]
Abstract
The accuracy and reliability of ultrasound are still insufficient to guarantee complete and safe nerve block for all patients. Injection of local anaesthetic close to, but not touching, the nerve is key to outcomes, but the exact relationship between the needle tip and nerve epineurium is difficult to evaluate, even with ultrasound. Ultrasound has insufficient resolution, tissues are difficult to discern due to acoustic impedance and needles are more difficult to see with increased angulation. The limitations of ultrasound have shifted the focus of innovation towards bio-markers that help detect needle tip position by utilising the physical properties of tissues, (e.g. pressure, electrical, optics, acoustic and elastic). Although most are at the laboratory stage and results are as yet only available from phantom or cadaver studies, clinical trials are imminent. For example, fine optical fibres placed within the lumen of block needles can measure needle tip pressure. Electrical impedance differentiates between intraneural and perineural needle tip placement. A new tip tracker needle has a piezo element embedded at its distal end that tracks the needle tip in-plane and out-of-plane as a blue/red or green circle depending on its relative location within the beam. Micro-ultrasound at the tip of the needle is in development. Early images using 40MHz in anaesthetised pigs reveal muscle striation, distinct epineurium and 30-40 fascicles > 75 micron in diameter. The next few years will see a technological revolution in tip-tracking technology that has the potential to improve patient safety and, in doing so, change practice.
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Affiliation(s)
- G A McLeod
- Ninewells Hospital, Dundee, UK.,Institute of Academic Anaesthesia, University of Dundee, UK.,University of East Anglia, Norwich, UK
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12
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Saporito A, Quadri C, Steinfeldt T, Wiesmann T, Cantini LM, Capdevila X. Early detection of intraneural and intravascular injections with real-time injection pressure monitoring in cadavers. Acta Anaesthesiol Scand 2020; 64:1513-1518. [PMID: 33439487 DOI: 10.1111/aas.13681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Injection pressure monitoring can help detecting the needle tip position and avoid intraneural injection. However, it shall be measured at the needle tip in order to be accurate and reproducible with any injection system and non operator-dependent. With an innovative system monitoring the injection pressure right at the needle tip we show that it is possible to early detect an intraneural and also an intravascular injection. METHODS We performed supraclavicular block-like procedures under real-time ultrasound guidance on two fresh cadaver torsos using a sensing needle with an optical fiber pressure sensor within the shaft continuously measuring injection pressure at the needle tip. A total of 45 ultrasound-guided injections were performed (15 perineural, 15 intraneural and 15 intravenous injections). RESULTS Mean (SD) injection pressure after only 1 mL injected volume was already significantly higher for the intraneural compared to the perineural injections: 70.46 kPa (11.72) vs 8.34 (4.68) kPa; P < .001. Mean (SD) injection pressure at 1 mL injected volume was significantly lower for the intravascular compared to the perineural injections: 1.51 (0.48) vs 8.34 (4.68) kPa; P < .001. CONCLUSIONS Our results show that injection pressure monitoring at the needle tip has the potential to help identifying an accidental intraneural or intravascular injection at a very early stage.
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Affiliation(s)
- Andrea Saporito
- Department of Anesthesia Bellinzona Regional Hospital Bellinzona Switzerland
| | - Christian Quadri
- Department of Anesthesia Lugano Regional Hospital Lugano Switzerland
| | - Thorsten Steinfeldt
- Department of Anesthesia and Intensive CareDiakonie‐Klinikum Schwäbisch Hall gGmbH Schwäbisch Hall Germany
| | - Thomas Wiesmann
- Department of Anesthesia and Intensive Care Philipps‐University Hospital Marburg Germany
| | - Laura Micòl Cantini
- Department of Anesthesia Bellinzona Regional Hospital Bellinzona Switzerland
| | - Xavier Capdevila
- Department of Anesthesia and Intensive Care Montpellier University Hospital University Montpellier Montpellier France
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Capdevila M, Choquet O, Saporito A, Djanikian F, Swisser F, Marques M, Bringuier S, Capdevila X. Injection pressure monitoring during peripheral nerve blocks: from bench to operating theatre. Anaesth Crit Care Pain Med 2020; 39:603-610. [DOI: 10.1016/j.accpm.2020.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/05/2020] [Accepted: 03/18/2020] [Indexed: 10/23/2022]
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Desmet M, Bindelle S, Breebaart M, Camerlynck H, Casaer S, Fourneau K, Gautier P, Goffin P, Lecoq J, Lenders I, Leunen I, Van Aken D, Van Houwe P, Van Hooreweghe S, Vermeylen K, Sermeus I. Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.3.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.
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Capdevila M, Saporito A, Quadri C, Dick M, Cantini LM, Bringuier S, Capdevila X. Real-time continuous monitoring of injection pressure during peripheral nerve blocks in fresh cadavers. Anaesth Crit Care Pain Med 2020; 39:597-601. [PMID: 32771496 DOI: 10.1016/j.accpm.2020.03.021] [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: 08/09/2019] [Revised: 02/21/2020] [Accepted: 03/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of unintentional intraneural injection while performing peripheral nerve block has been estimated to be 15% under real-time ultrasound guidance. Injection pressure increase may detect an intraneural injection. Real-time injection pressure changes throughout an entire nerve block procedure in relationship with needle tip location have never been reported. METHODS A new method was developed to precisely monitor the injection pressure curve during nerve blocks, based on a miniaturised Fabbri-Perrot pressure sensor. We tested in three fresh cadavers the ability of continuous pressure monitoring to discriminate between different tissues, as the injection pressure curve ascending slope, shape and plateau pressure value depend on tissue compliance. Injections of saline were performed by an electronic syringe pump with three different constant flow rates. Pressure was measured simultaneously at the tip and in the tubing of the needle. RESULTS At 10 mL/min injection flow, median peak injection pressure in the intraneural group at the needle tip was 315 mmHg, while at the perineural location it was 100 mmHg (p < 0.05). Median injection pressure was 95 mmHg in the intramuscular locations group, and 819 mmHg when a muscular fascia was indented (p < 0.05). A significant difference was noted for pressure measurements between the proximal port of the needle and the tip, 625 and 417 respectively. CONCLUSIONS Based on significant differences in injection pressure values and curve shapes, the system was able to discriminate between four needle tip locations. This may help with needle tracking while performing a peripheral nerve block.
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Affiliation(s)
- Mathieu Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Andrea Saporito
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland
| | - Christian Quadri
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland
| | - Maxime Dick
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Laura M Cantini
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland.
| | - Sophie Bringuier
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Department of Medical Biostatistics, Arnaud de Villeneuve University Hospital, 34295 Montpellier Cedex 5, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Inserm Unit 1051 Montpellier NeuroSciences Institute, Montpellier University, 34295 Montpellier Cedex 5, France
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Carassiti M, De Filippis A, Palermo P, Valenti C, Costa F, Massaroni C, Schena E. Injection pressures measuring for a safe peripheral nerve block. Minerva Anestesiol 2019; 85. [DOI: 10.23736/s0375-9393.19.13518-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Damjanovska M, Cvetko E, Kuroda MM, Seliskar A, Plavec T, Mis K, Podbregar M, Pintaric TS. Neurotoxicity of intraneural injection of bupivacaine liposome injectable suspension versus bupivacaine hydrochloride in a porcine model. Vet Anaesth Analg 2019; 46:236-245. [DOI: 10.1016/j.vaa.2018.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 09/04/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
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Rambhia M, Gadsden J. Pressure monitoring: The evidence so far. Best Pract Res Clin Anaesthesiol 2019; 33:47-56. [DOI: 10.1016/j.bpa.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/15/2022]
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Barrington MJ, Lirk P. Reducing the risk of neurological complications after peripheral nerve block: what is the role of pressure monitoring? Anaesthesia 2018; 74:9-12. [PMID: 30339281 DOI: 10.1111/anae.14469] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- M J Barrington
- Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Vic., Australia.,Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Vic., Australia
| | - P Lirk
- Department of Anesthesiology, Peri-operative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Saporito A, Quadri C, Capdevila X. The ability of a real-time injection pressure monitoring system to discriminate between perineural and intraneural injection of the sciatic nerve in fresh cadavers. Anaesthesia 2018; 73:1118-1122. [DOI: 10.1111/anae.14330] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- A. Saporito
- Bellinzona Regional Hospital; Bellinzona Switzerland
| | - C. Quadri
- Service of Anaesthesia; Lugano Regional Hospital; Lugano Switzerland
| | - X. Capdevila
- Montpellier University Hospital; University Montpellier; France
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Saporito A, Quadri C, Kloth N, Capdevila X. The effect of rate of injection on injection pressure profiles measured using in-line and needle-tip sensors: an in-vitro study. Anaesthesia 2018; 74:64-68. [DOI: 10.1111/anae.14415] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2018] [Indexed: 11/26/2022]
Affiliation(s)
- A. Saporito
- Bellinzona Regional Hospital; Bellinzona Switzerland
| | - C. Quadri
- Service of Anaesthesia; Lugano Regional Hospital; Lugano Switzerland
| | - N. Kloth
- See-Spital Horgen and Kilchberg; Switzerland
| | - X. Capdevila
- Montpellier University Hospital; University Montpellier; France
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Gadsden J. Current devices used for the monitoring of injection pressure during peripheral nerve blocks. Expert Rev Med Devices 2018; 15:571-578. [DOI: 10.1080/17434440.2018.1507731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jeff Gadsden
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Krol A, Vala A, Phylactides L, Szarko M, Reina MA, De Andres J. Injection pressure mapping of intraneural vs. perineural injections: further lessons from cadaveric studies. Minerva Anestesiol 2018; 84:907-918. [DOI: 10.23736/s0375-9393.18.12230-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Advances of Techniques in Deep Regional Blocks. BIOMED RESEARCH INTERNATIONAL 2018; 2017:7268308. [PMID: 29349079 PMCID: PMC5733986 DOI: 10.1155/2017/7268308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 11/17/2022]
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Reply to: importance of half-the-air pressure test in Shamrock lumbar plexus block. Eur J Anaesthesiol 2018; 33:784-5. [PMID: 27096903 DOI: 10.1097/eja.0000000000000466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Quadri C, Saporito A, Capdevila X. Real-time continuous monitoring of injection pressure at the needle tip for peripheral nerve blocks: description of a new method. Anaesthesia 2017; 73:187-194. [DOI: 10.1111/anae.14041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 12/01/2022]
Affiliation(s)
- C. Quadri
- Anaesthesiology Department; Lugano Regional Hospital; Lugano Switzerland
| | - A. Saporito
- Anaesthesiology Department; Bellinzona Regional Hospital; Bellinzona Switzerland
| | - X. Capdevila
- Department of Anaesthesiology and Critical Care Medicine; Inserm Unit 1051; Montpellier University Hospital; University Montpellier 1; Montpellier France
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Opening Injection Pressure Is Higher in Intraneural Compared With Perineural Injections During Simulated Nerve Blocks of the Lower Limb in Fresh Human Cadavers. Reg Anesth Pain Med 2017; 42:362-367. [DOI: 10.1097/aap.0000000000000548] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Munirama S, Zealley K, Schwab A, Columb M, Corner G, Eisma R, McLeod G. Trainee anaesthetist diagnosis of intraneural injection—a study comparing B-mode ultrasound with the fusion of B-mode and elastography in the soft embalmed Thiel cadaver model. Br J Anaesth 2016; 117:792-800. [DOI: 10.1093/bja/aew337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/13/2022] Open
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