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Sharapi M, Yassin M, Arafeh Y, Afifi E, El-Samahy M, Thomas J. Efficacy and safety of extrafascial injection versus intrafascial injection for interscalene brachial plexus block: a systematic review and meta-analysis. Minerva Anestesiol 2024; 90:550-560. [PMID: 38305015 DOI: 10.23736/s0375-9393.23.17807-2] [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: 02/03/2024]
Abstract
INTRODUCTION This systematic review and meta-analysis aimed to assess the efficacy and safety of interscalene brachial plexus block (ISB) techniques in upper limb and shoulder surgeries. EVIDENCE ACQUISITION We conducted a comprehensive search of PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, Medline, and Scopus databases up to May 14th, 2023. We employed a search strategy involving keywords such as "brachial plexus block," "interscalene brachial plexus block," "ISB," "extrafascial," and "intrafascial," without applying search restrictions or filters. Eligible studies consisted of randomised controlled trials (RCTs) that compared extrafascial and intrafascial ISB techniques in adult patients undergoing upper limb and shoulder surgeries. EVIDENCE SYNTHESIS Our analysis included six RCTs encompassing 485 participants. Extrafascial injection demonstrated superiority over intrafascial injection in reducing the incidence of hemidiaphragmatic paresis (RR 0.33, 95% CI 0.124 to 0.47, P<0.00001) and preserving respiratory function (MS 0.31, 95% CI 0.1 to 0. 52, P=0.003 FEV1 in liters). Additionally, extrafascial ISB exhibited a lower risk of block-related complications (RR 0.35, 95% CI 0.25 to 0.50, P<0.00001). However, the intrafascial technique offered a faster sensory and motor block onset. The duration of sensory block did not significantly differ. The incidence of Horner syndrome showed no statistically significant difference. CONCLUSIONS Our findings favor extrafascial ISB techniques because they reduce hemidiaphragmatic paresis, preserve respiratory function, and lower block-related complications. However, further research is necessary to establish their safety and efficacy in specific patient populations.
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Affiliation(s)
- Mahfouz Sharapi
- Department of Anesthesiology and Intensive Care, Our Lady of Lourdes Hospital, Drogheda, Ireland -
| | - Mazen Yassin
- Faculty of Medicine, Helwan University, Helwan, Egypt
| | - Yusra Arafeh
- Jordan University of Science and Technology, Ar-Ramtha, Jordan
| | - Eslam Afifi
- Faculty of Medicine, Benha Medical University, Benha, Egypt
| | | | - Jubil Thomas
- Department of Anesthesiology and Intensive Care, Our Lady of Lourdes Hospital, Drogheda, Ireland
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Tseng KY, Wang HC, Cheng KF, Wang YH, Chang LL, Cheng KI. Sciatic Nerve Intrafascicular Injection Induces Neuropathy by Activating the Matrix Modulators MMP-9 and TIMP-1. Front Pharmacol 2022; 13:859982. [PMID: 35694244 PMCID: PMC9178525 DOI: 10.3389/fphar.2022.859982] [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: 01/25/2022] [Accepted: 04/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Peripheral nerve block (PNB) under echo guidance may not prevent intrafascicular anesthetic injection-induced nerve injury. This study investigated whether unintended needle piercing alone, or the intrafascicular nerve injectant could induce neuropathy. Methods: 120 adult male Sprague-Dawley rats were divided into four groups: 1) group S, only the left sciatic nerve was exposed; 2) group InF-P, the left sciatic nerve was exposed and pierced with a 30 G needle; 3) group InF-S, left sciatic nerve was exposed and injected with saline (0.9% NaCl 30 µL); 4) group InF-R, left sciatic nerve was exposed and injected with 0.5% (5 mg/mL, 30 µL) ropivacaine. Behaviors of thermal and mechanical stimuli responses from hindpaws, sciatic nerve vascular permeability and tight junction protein expression, and macrophage infiltration were assessed. Pro-inflammatory cytokine expression and TIMP-1 and MMP-9 activation at the injection site and the swollen, and distal sites of the sciatic nerve were measured by cytokine array, western blotting, and immunofluorescence of POh14 and POD3. Results: Intrafascicular saline and ropivacaine into the sciatic nerve, but not needle piercing alone, significantly induced mechanical allodynia that lasted for seven days. In addition, the prior groups increased vascular permeability and macrophage infiltration, especially in the swollen site of the sciatic nerve. Thermal hypersensitivity was induced and lasted for only 3 days after intrafascicular saline injection. Obvious upregulation of TIMP-1 and MMP-9 on POh6 and POh14 occurred regardless of intrafascicular injection or needle piercing. Compared to the needle piercing group, the ratio of MMP-9/TIMP-1 was significantly higher in the intrafascicular injectant groups at the injected and swollen sites of the sciatic nerve. Although no gross changes in the expressions of tight junction proteins (TJPs) claudin-5 and ZO-1, the TJPs turned to apparent fragmentation and fenestration-like degenerative change in swollen endothelial cells and thickened microvessels. Conclusion: Intrafascicular nerve injection is a distinct mechanism that induces neuropathy. It is likely that the InF nerve injection-induced neuropathy was largely due to dramatic, but transient, increases in enzymatic activities of MMP-9 and activating TIMP-1 in the operated nerves. The changes in enzymatic activities then contributed to certain levels of extracellular matrix degradation, which leads to increases in endoneurial vascular permeability.
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Affiliation(s)
- Kuang-Yi Tseng
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Chen Wang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kai-Feng Cheng
- Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Hsuan Wang
- Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lin-Li Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Microbiology and Immunology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Osterc T, Rupnik B, Rosskopf AB, Borgeat A, Eichenberger U, Aguirre J. Inadvertent Placement of an Infraclavicular Catheter in the Interscalene Region With an Unusual Complication: A Case Report. A A Pract 2022; 16:e01572. [DOI: 10.1213/xaa.0000000000001572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Panchamia JK, Jagannathan R, Pulos BP, Amundson AW, Sanchez-Sotelo J, Martin DP, Smith HM. The effects of shoulder arthroscopy on ultrasound image quality of the interscalene brachial plexus: a pre-procedure vs post-procedure comparative study. BMC Anesthesiol 2021; 21:187. [PMID: 34243720 PMCID: PMC8268244 DOI: 10.1186/s12871-021-01409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). METHODS This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes. RESULTS Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05). CONCLUSION Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible. TRIAL REGISTRATION ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).
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Affiliation(s)
- Jason K Panchamia
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ram Jagannathan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Bridget P Pulos
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Hugh M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Ultrasound-Guided Peripheral Nerve Blocks Performed by Orthopedic Surgeons: A Retrospective, Multicenter Study in Akita Prefecture, Japan. Adv Orthop 2021; 2021:5580591. [PMID: 33777455 PMCID: PMC7969096 DOI: 10.1155/2021/5580591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
The shortage of doctors is a societal problem, especially in rural areas such as Akita Prefecture, Japan. Therefore, it is not unusual in Akita for orthopedic surgeons to perform upper and lower limb surgeries under ultrasound-guided peripheral nerve blocks managed by the operators themselves. Multicenter studies of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons have not been reported. The purpose of this study was to clarify the safety and reliability of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons in Akita. A total of 1,674 upper extremity surgery cases operated under ultrasound-guided peripheral nerve blocks at 8 hospitals in Akita prefecture from April 2016 to April 2018 were investigated retrospectively. These blocks were performed by a total of 37 orthopedic surgeons, including senior surgeons and residents. In 321 of the 1,674 cases (19%), local anesthetics were added to the surgical field. Two cases with special factors were converted to general anesthesia. There were 2 cases of complications associated with the nerve block, but they were all transient and recovered promptly. The block site and the hospital where the block was performed showed a significant relationship with the addition of local anesthetics to the surgical site (P < 0.001). Surgery time, age at surgery, and surgical site showed no significant relationships with the addition of local anesthetics. The volume of the anesthetic used for the nerve block showed a significant inverse relationship with the addition of local anesthetics (P=0.040). Many orthopedic surgeons in Akita prefecture began to perform ultrasound-guided peripheral nerve blocks, which had a reliable anesthesia effect with no noticeable complications, whether performed by residents or senior orthopedic surgeons, and this is a useful anesthetic technique for orthopedic surgeons.
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Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial. PLoS One 2021; 16:e0246792. [PMID: 33600437 PMCID: PMC7891753 DOI: 10.1371/journal.pone.0246792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022] Open
Abstract
Background This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block. Methods 208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner’s syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting. Results Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2–6] vs. 6 min [4–10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome. Conclusion The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.
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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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Injection pressure monitoring at the needle tip for detection of perineural and nerve-contact position: a cadaver study. Can J Anaesth 2020; 67:1076-1077. [DOI: 10.1007/s12630-020-01586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 11/25/2022] Open
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Dang DY, McGarry SM, Melbihess EJ, Haytmanek CT, Stith AT, Griffin MJ, Ackerman KJ, Hirose CB. Comparison of Single-Agent Versus 3-Additive Regional Anesthesia for Foot and Ankle Surgery. Foot Ankle Int 2019; 40:1195-1202. [PMID: 31307211 DOI: 10.1177/1071100719859020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared the results of regional blocks containing a single anesthetic, bupivacaine, with those containing bupivacaine and 3 additives (buprenorphine, clonidine, and dexamethasone) in patients undergoing foot and ankle surgery. METHODS Eighty patients undergoing foot and ankle surgery over a 9-month period were prospectively enrolled and randomized to receive a peripheral nerve block containing either a single anesthetic (SA) or one with 3 additives (TA). Patients, surgeons, and anesthesiologists were blinded to the groups. Patients maintained pain diaries and were evaluated at 1 and 12 weeks postoperatively. Fifty-six patients completed the study. RESULTS The TA group had a longer duration of analgesic effect than the SA group (average 82 vs 34 hours, P < .05). Forty-eight hours after surgery, 93% of SA blocks, compared with 34% of TA blocks, had completely worn off. The TA group had a longer duration of sensory effects. At 3 months, 10 of 26 (38.5%) TA patients, compared with 3 of 30 (10%) SA patients, reported postoperative neurologic symptoms. Pain scores in both groups were not statistically different at 1 week or 3 months after surgery. Patients in both groups were similarly satisfied with their blocks. CONCLUSION Both types of nerve blocks provided equivalent pain control and patient satisfaction in patients undergoing foot and ankle surgery. The 3-additive agent blocks were associated with a longer duration of pain relief and a longer duration of numbness, as well as higher rates of postoperative neurologic symptoms. Longer pain relief may be obtained at the cost of prolonged sensory deficits. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Debbie Y Dang
- Saint Alphonsus Regional Medical Center Coughlin Clinic, Boise, ID, USA
| | | | | | | | - Andrew T Stith
- Wyoming Orthopaedics and Sports Medicine, Cheyenne, WY, USA
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O'Donnell BD, Loughnane F. Novel nerve imaging and regional anesthesia, bio-impedance and the future. Best Pract Res Clin Anaesthesiol 2019; 33:23-35. [DOI: 10.1016/j.bpa.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
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Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting. J Clin Anesth 2018; 48:22-27. [DOI: 10.1016/j.jclinane.2018.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/13/2018] [Accepted: 04/27/2018] [Indexed: 01/22/2023]
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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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Park YU, Cho JH, Lee DH, Choi WS, Lee HD, Kim KS. Complications After Multiple-Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone. Foot Ankle Int 2018; 39:731-735. [PMID: 29366344 DOI: 10.1177/1071100717753954] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Single or combined multiple-site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks. METHODS Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later. RESULTS Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients' last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks. CONCLUSION There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple-site blocks did not increase the rate of neurologic complications. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Young Uk Park
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Jae Ho Cho
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Doo Hyung Lee
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Wan Sun Choi
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Han Dong Lee
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Keun Soo Kim
- 1 Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
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Sondekoppam RV, Tsui BCH. Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks. Anesth Analg 2017; 124:645-660. [DOI: 10.1213/ane.0000000000001804] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Affiliation(s)
- Paul E Bigeleisen
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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Sciatic Nerve Intrafascicular Lidocaine Injection-induced Peripheral Neuropathic Pain. Clin J Pain 2016; 32:513-21. [DOI: 10.1097/ajp.0000000000000293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lin JA, Chuang TY, Yao HY, Yang SF, Tai YT. Ultrasound standard of peripheral nerve block for shoulder arthroscopy: a single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. Br J Anaesth 2016; 115:932-4. [PMID: 26582855 DOI: 10.1093/bja/aev384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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The Requisites of Needle-to-Nerve Proximity for Ultrasound-Guided Regional Anesthesia. Reg Anesth Pain Med 2016; 41:221-8. [DOI: 10.1097/aap.0000000000000201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia. Reg Anesth Pain Med 2016; 41:181-94. [DOI: 10.1097/aap.0000000000000331] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block. Reg Anesth Pain Med 2015; 41:50-5. [PMID: 26650431 DOI: 10.1097/aap.0000000000000346] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES High opening injection pressures (OIPs) have been shown to predict sustained needle tip contact with the roots of the brachial plexus. Such roots have a uniquely high ratio of fascicular versus connective tissue. It is unknown if this relationship is preserved during multifascicular nerve blockade. We hypothesized that OIP can predict needle-nerve contact during femoral nerve block, as well as detect needle contact with the fascia iliaca. METHODS Twenty adults scheduled for femoral block were recruited. Using ultrasound, a 22-gauge needle was sequentially placed in 4 locations: indenting the fascia iliaca, advanced through the fascia iliaca while lateral to the nerve, slightly indenting the femoral nerve, and withdrawn from the nerve 1 mm. At each location, the OIP required to initiate an injection of 1 mL D5W (5% dextrose in water) at 10 mL/min was recorded. Blinded investigators performed evaluations and aborted injections when an OIP of 15 psi was reached. RESULTS Opening injection pressure was 15 psi or greater for 90% and 100% of cases when the needle indented the femoral nerve and fascia iliaca, respectively. Opening injection pressure was less than 15 psi for all 20 patients when the needle was withdrawn 1 mm from the nerve as well as at the subfascial position (McNemar χ2 P < 0.001). CONCLUSIONS Opening injection pressure greater than 15 psi was associated with a block needle tip position slightly indenting the epineurium of the femoral nerve (90%) and the fascia iliaca (100%). Needle tip positions not indenting these structures were associated with OIP of less than 15 psi (100%).
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Ryu T, Kil BT, Kim JH. Comparison Between Ultrasound-Guided Supraclavicular and Interscalene Brachial Plexus Blocks in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective, Randomized, Parallel Study. Medicine (Baltimore) 2015; 94:e1726. [PMID: 26448030 PMCID: PMC4616738 DOI: 10.1097/md.0000000000001726] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Although supraclavicular brachial plexus block (SCBPB) was repopularized by the introduction of ultrasound, its usefulness in shoulder surgery has not been widely reported. The objective of this study was to compare motor and sensory blockades, the incidence of side effects, and intraoperative opioid analgesic requirements between SCBPB and interscalene brachial plexus block (ISBPB) in patients undergoing arthroscopic shoulder surgery. Patients were randomly assigned to 1 of 2 groups (ISBPB group: n = 47; SCBPB group: n = 46). The side effects of the brachial plexus block (Horner's syndrome, hoarseness, and subjective dyspnea), the sensory block score (graded from 0 [no cold sensation] to 100 [intact sensation] using an alcohol swab) for each of the 5 dermatomes (C5-C8 and T1), and the motor block score (graded from 0 [complete paralysis] to 6 [normal muscle force]) for muscle forces corresponding to the radial, ulnar, median, and musculocutaneous nerves were evaluated 20 min after the brachial plexus block. Fentanyl was administered in 50 μg increments when the patients complained of pain that was not relieved by the brachial plexus block. There were no conversions to general anesthesia due to a failed brachial plexus block. The sensory block scores for the C5 to C8 dermatomes were significantly lower in the ISBPB group. However, the percentage of patients who received fentanyl was comparable between the 2 groups (27.7% [ISBPB group] and 30.4% [SCBPB group], P = 0.77). SCBPB produced significantly lower motor block scores for the radial, ulnar, and median nerves than did ISBPB. A significantly higher incidence of Horner's syndrome was observed in the ISBPB group (59.6% [ISBPB group] and 19.6% [SCBPB group], P < 0.001). No patient complained of subjective dyspnea. Despite the weaker degree of sensory blockade provided by SCBPB in comparison to ISBPB, opioid analgesic requirements are similar during arthroscopic shoulder surgery under both brachial plexus blocks. However, SCBPB produces a better motor blockade and a lower incidence of Horner's syndrome than ISBPB.
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Affiliation(s)
- Taeha Ryu
- From the Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Republic of Korea
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25
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Histological confirmation of needle tip position during ultrasound-guided interscalene block: a randomized comparison between the intraplexus and the periplexus approach. Can J Anaesth 2015; 62:1295-302. [PMID: 26335906 DOI: 10.1007/s12630-015-0468-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 07/20/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Ultrasound-guided interscalene block can be performed using either periplexus or intraplexus needle placement. In this novel study, we histologically examined the needle tip position in relation to the neural tissues with the two techniques. Our objective was to investigate the variable risk of subepineurial needle tip placement resulting from the two ultrasound-guided techniques. METHODS In an embalmed cadaveric model, periplexus or intraplexus interscalene injections were performed with the side, order, and technique assigned randomly. Under real-time ultrasound guidance, the block needle was placed next to the hyperechoic layer of the plexus (periplexus) or between the hypoechoic nerve roots (intraplexus). Once positioned, 0.1 mL of black acrylic ink was injected. The brachial plexus tissues were then removed and histology sections were prepared and then coded in order to blind two reviewers to group allocation. The area of ink staining was used to determine needle tip location, and the groups were compared for the presence of subepineurial ink. RESULTS Twenty-six cadavers had each of the blocks performed on either brachial plexus (i.e., 52 injections). No subepineurial ink deposits were observed in the periplexus group (0%), but subepineurial ink deposition was observed in 3/26 (11.5%) intraplexus injections (odds ratio, 0; 95% confidence interval, 0 to 2.362; P = 0.235). Furthermore, in the intraplexus group, two (of the three) subepineurial ink deposits were observed under the perineurium. CONCLUSION Although our study was somewhat underpowered due to a lower than previously reported rate of subepineurial needle tip positioning, our results suggest that there may be an increased likelihood of subepineurial needle tip position with the intraplexus approach. The periplexus technique resulted in no subepineurial spread of ink, suggesting that this approach may be less likely to result in mechanical trauma to nerves from direct needle injury.
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Brull R, Hadzic A, Reina MA, Barrington MJ. Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade. Reg Anesth Pain Med 2015; 40:479-90. [PMID: 25974275 DOI: 10.1097/aap.0000000000000125] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review synthesizes anatomical, anesthetic, surgical, and patient factors that may contribute to neurologic complications associated with peripheral nerve blockade. Peripheral nerves have anatomical features unique to a given location that may influence risk of injury. Peripheral nerve blockade-related peripheral nerve injury (PNI) is most severe with intrafascicular injection. Surgery and its associated requirements such as positioning and tourniquet have specific risks. Patients with preexisting neuropathy may be at an increased risk of postoperative neurologic dysfunction. Distinguishing potential causes of PNI require clinical assessment and investigation; a definitive diagnosis, however, is not always possible. Fortunately, most postoperative neurologic dysfunction appears to resolve with time, and the incidence of serious long-term nerve injury directly attributable to peripheral nerve blockade is relatively uncommon. Nonetheless, despite the use of ultrasound guidance, the risk of block-related PNI remains unchanged. WHAT'S NEW Since the 2008 Practice Advisory, new information has been published, furthering our understanding of the microanatomy of peripheral nerves, mechanisms of peripheral nerve injection injury, toxicity of local anesthetics, the etiology of and monitoring methods, and technologies that may decrease the risk of nerve block-related peripheral nerve injury.
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Affiliation(s)
- Richard Brull
- From the *Departments of Anesthesia, Toronto Western Hospital, University Health Network, and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, St Luke's and Roosevelt Hospitals, New York, NY; ‡School of Medicine, CEU San Pablo University, and Madrid Montepríncipe University Hospital, Madrid, Spain; and §Department of Anaesthesia, St Vincent's Hospital; Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Helen L, O'Donnell BD, Moore E. Nerve localization techniques for peripheral nerve block and possible future directions. Acta Anaesthesiol Scand 2015; 59:962-74. [PMID: 25997933 DOI: 10.1111/aas.12544] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/24/2015] [Accepted: 04/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block. METHODS This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem. RESULTS To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques. CONCLUSIONS Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.
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Affiliation(s)
- L. Helen
- Sensing and Separation Group; Chemistry Department and Life Science Interface Group; Tyndall National Institute; University College Cork; Cork Ireland
| | - B. D. O'Donnell
- Department of Anesthesia; Cork University Hospital & ASSERT for Health Centre; University College Cork; Cork Ireland
| | - E. Moore
- Sensing and Separation Group; Chemistry Department and Life Science Interface Group; Tyndall National Institute; University College Cork; Cork Ireland
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Lam NCK, Fishburn SJ, Hammer AR, Petersen TR, Gerstein NS, Mariano ER. A Randomized Controlled Trial Evaluating the See, Tilt, Align, and Rotate (STAR) Maneuver on Skill Acquisition for Simulated Ultrasound-Guided Interventional Procedures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1019-1026. [PMID: 26014321 DOI: 10.7863/ultra.34.6.1019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Achieving the best view of the needle and target anatomy when performing ultrasound-guided interventional procedures requires technical skill, which novices may find difficult to learn. We hypothesized that teaching novice performers to use 4 sequential steps (see, tilt, align, and rotate [STAR] method) to identify the needle under ultrasound guidance is more efficient than training with the commonly described probe movements of align, rotate, and tilt (ART). METHODS This study compared 2 instructional methods for transducer manipulation including alignment of a probe and needle by novices during a simulated ultrasound-guided nerve block. Right-handed volunteers between the ages of 18 and 55 years who had no previous ultrasound experience were recruited and randomized to 1 of 2 groups; one group was trained to troubleshoot misalignment with the ART method, and the other was trained with the new STAR maneuver. Participants performed the task, consisting of directing a needle in plane to 3 targets in a standardized gelatin phantom 3 times. The performance assessor and data analyst were blinded to group assignment. RESULTS Thirty-five participants were recruited. The STAR group was able to complete the task more quickly (P < .001) and visualized the needle in a greater proportion of the procedure time (P = .004) compared to the ART group. All STAR participants were able to complete the task, whereas 41% of ART participants abandoned the task (P = .003). CONCLUSIONS Novices are able to complete a simulated ultrasound-guided nerve block more quickly and efficiently when trained with the 4-step STAR maneuver compared to the ART method.
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Affiliation(s)
- Nicholas C K Lam
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.)
| | - Steven J Fishburn
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.)
| | - Angie R Hammer
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.)
| | - Timothy R Petersen
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.)
| | - Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.)
| | - Edward R Mariano
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico USA (N.C.K.L., S.J.F., A.R.H., T.R.P., N.S.G.); Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California USA (E.R.M.); and Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.R.M.).
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29
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An improvised pressure gauge for regional nerve blockade/anesthesia injections: an initial study. J Clin Monit Comput 2015; 29:673-9. [DOI: 10.1007/s10877-015-9701-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
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31
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O'Donnell B, O'Sullivan O, Gallagher A, Shorten G. Robotic assistance with needle guidance. Br J Anaesth 2015; 114:708-709. [DOI: 10.1093/bja/aev045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Block awake or asleep: still a conundrum? Reg Anesth Pain Med 2015; 40:176. [PMID: 25688725 DOI: 10.1097/aap.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Gadsden J, Latmore M, Levine DM. Evaluation of the eZono 4000 with eZGuide for ultrasound-guided procedures. Expert Rev Med Devices 2014; 12:251-61. [PMID: 25543816 DOI: 10.1586/17434440.2015.995095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ultrasound-guided procedures are increasingly common in a variety of acute care settings, such as the operating room, critical care unit and emergency room. However, accurate judgment of needle tip position using traditional ultrasound technology is frequently difficult, and serious injury can result from inadvertently advancing beyond or through the target. Needle navigation is a recent innovation that allows the clinician to visualize the needle position and trajectory in real time as it approaches the target. A novel ultrasound machine has recently been introduced that is portable and designed for procedural guidance. The eZono 4000™ features an innovative needle navigation technology that is simple to use and permits the use of a wide range of commercially available needles, avoiding the inconvenience and cost of proprietary equipment. This article discusses this new ultrasound machine in the context of other currently available ultrasound machines featuring needle navigation.
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Affiliation(s)
- Jeff Gadsden
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Abstract
The type of anesthesia chosen is an integral part of the decision-making process for arteriovenous access construction. We discuss the different types of anesthesia used, with emphasis on brachial plexus block, which is potentially safer than general anesthesia in this fragile patient population with end-stage renal disease. Brachial plexus block is superior to local anesthesia and enables the use of a tourniquet to minimize potential damage to the blood vessels during anastomosis using microsurgery techniques, and does not lead to the vasospasm that may be seen with local anesthesia. Regional anesthesia has a beneficial sympathectomy-like effect that causes vasodilation with increased blood flow during surgery and in the fistula postoperatively that may prevent early thrombosis and potentially improve outcome.
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Auyong DB, Cabbabe AA. Selective blockade of the dorsal scapular nerve for scapula surgery. J Clin Anesth 2014; 26:684-7. [DOI: 10.1016/j.jclinane.2014.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 06/02/2014] [Accepted: 06/07/2014] [Indexed: 10/24/2022]
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Munirama S, Joy J, Columb M, Habershaw R, Eisma R, Corner G, Cochran S, McLeod G. A randomised, single-blind technical study comparing the ultrasonic visibility of smooth-surfaced and textured needles in a soft embalmed cadaver model. Anaesthesia 2014; 70:537-42. [DOI: 10.1111/anae.12925] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2014] [Indexed: 11/28/2022]
Affiliation(s)
- S. Munirama
- Institute of Academic Anaesthesia; University of Dundee; Dundee UK
| | - J. Joy
- Institute for Medical Science and Technology; University of Dundee; Dundee UK
| | - M. Columb
- Departments of Anaesthesia & Intensive Care Medicine; Wythenshawe Hospital; Manchester UK
| | - R. Habershaw
- Institute for Medical Science and Technology; University of Dundee; Dundee UK
| | - R. Eisma
- Centre for Anatomy and Human Identification; University of Dundee; Dundee UK
| | | | - S. Cochran
- Institute for Medical Science and Technology; University of Dundee; Dundee UK
| | - G. McLeod
- Institute of Academic Anaesthesia; University of Dundee; Dundee UK
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Patil JJ, Ford S, Egeler C, Williams DJ. The effect of needle dimensions and infusion rates on injection pressures in regional anaesthesia needles: a bench-top study. Anaesthesia 2014; 70:183-9. [PMID: 25290190 DOI: 10.1111/anae.12869] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 11/27/2022]
Abstract
Animal studies have shown that injection pressures > 75 kPa indicate probable intrafascicular needle tip position. This study describes the flow/pressure characteristics of seven common needle systems. A syringe pump delivered flow rates of 5, 6.67, 10, 13.3, 15 and 20 ml.min(-1) through these needle systems, while keeping the needle tips open to atmosphere. A pressure transducer connected between the syringe and needle provided a real-time graphical display for analysis. Mean plateau pressures increased linearly with flow and with decreasing needle diameter (2.7-92 kPa). Flow rates > 17 ml.min(-1) and needle sizes 22 G and smaller produced mean plateau pressures > 75 kPa. Pressure monitors upstream from the needle may produce false-positive alarms at high flow rates due to needle resistance, and unreliable readings due to non-laminar flow. We recommend injection rates ≤ 15 ml.min(-1) (0.25 ml.s(-1) ) to reduce the effect of factors upstream from the needle tip as a cause of high pressure readings.
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Affiliation(s)
- J J Patil
- Department of Anaesthesia and Intensive Care, Airedale General Hospital, Steeton, UK
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Case Scenario: Postoperative Brachial Plexopathy Associated with Infraclavicular Brachial Plexus Blockade. Anesthesiology 2014; 121:383-7. [DOI: 10.1097/aln.0000000000000211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Opening Injection Pressure Consistently Detects Needle–Nerve Contact during Ultrasound-guided Interscalene Brachial Plexus Block. Anesthesiology 2014; 120:1246-53. [DOI: 10.1097/aln.0000000000000133] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background:
Needle trauma may cause neuropathy after nerve blockade. Even without injection, nerve injury can result from forceful needle–nerve contact (NNC). High opening injection pressures (OIPs) have been associated with intrafascicular needle tip placement and nerve damage; however, the relationship between OIP and NNC is unclear. The authors conducted a prospective, observational study to define this relationship.
Methods:
Sixteen patients scheduled for shoulder surgery under interscalene block were enrolled if they had clear ultrasound images of the brachial plexus roots. A 22-gauge stimulating needle was inserted within 1 mm of the root, and 1-ml D5W injected at 10 ml/min by using an automated pump. OIP was monitored using an in-line pressure manometer and injections aborted if 15 psi or greater. The needle was advanced to displace the nerve slightly (NNC), and the procedure repeated. Occurrence of evoked motor response and paresthesia were recorded.
Results:
Fifteen patients had at least one clearly visible root. OIP at 1 mm distance from the nerve was less than 15 psi (mean peak pressure 8.2 ± 2.4 psi) and the 1-ml injection could be completed in all but two cases (3%). In contrast, OIP during NNC was 15 psi or greater (mean peak pressure 20.9 ± 3.7 psi) in 35 of 36 injections. Aborting the injection when OIP reached 15 psi prevented commencement of injection in all cases of NNC except one.
Conclusion:
High OIP (≥15 psi) consistently detected NNC, suggesting that injection pressure monitoring may be useful in preventing injection against nerve roots during interscalene block.
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Ovesen J, Falstie-Jensen T, Christensen C. A Comparison of Subacromial Bursae Block, Suprascapular Nerve Block and Interscalene Brachial Plexus Block after Arthroscopic Shoulder Surgery. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/pst.2014.23017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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The Maximum Effective Needle-to-Nerve Distance for Ultrasound-Guided Interscalene Block. Reg Anesth Pain Med 2014; 39:56-60. [DOI: 10.1097/aap.0000000000000034] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Delaunay L, Ecoffey C. [Should we continue to use nerve stimulation alone for peripheral nerve blocks?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:217-9. [PMID: 23506955 DOI: 10.1016/j.annfar.2013.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bardou P, Merle JC, Woillard JB, Nathan-Denizot N, Beaulieu P. Electrical impedance to detect accidental nerve puncture during ultrasound-guided peripheral nerve blocks. Can J Anaesth 2012. [DOI: 10.1007/s12630-012-9845-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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44
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Where should the tip of the needle be located in ultrasound-guided peripheral nerve blocks? Curr Opin Anaesthesiol 2012; 25:596-602. [DOI: 10.1097/aco.0b013e328356bb40] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Moayeri N, Krediet A, Welleweerd J, Bleys R, Groen G. Early ultrasonographic detection of low-volume intraneural injection. Br J Anaesth 2012; 109:432-8. [DOI: 10.1093/bja/aes208] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Choquet O, Paqueron X, Capdevila X. [Can we perform an ultrasound-guided regional anesthesia in an anaesthetized patient?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:e187-e191. [PMID: 22841356 DOI: 10.1016/j.annfar.2012.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- O Choquet
- Service d'anesthésie et réanimation A, CHU Lapeyronie, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
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Belbachir A, Binhas M, Nouette-Gaulain K, Boccara G, Carles M. [Ultrasound guidance: Teaching]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:e179-e183. [PMID: 22841354 DOI: 10.1016/j.annfar.2012.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- A Belbachir
- Faculté de médecine, université Paris-Descartes, pôle d'anesthésie-réanimation, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris cedex, France.
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Abstract
PURPOSE OF REVIEW Is ultrasound guidance changing the practice of upper extremity regional anesthesia? This review will aim to describe the findings published in the literature during the previous 18 months. RECENT FINDINGS In some approaches to brachial plexus blockade, local anesthetic volumes may be reduced without deterioration of analgesic effect. However, even 10 ml of local injected into the interscalene space may result in diaphragmatic paresis. High-resolution ultrasonography has revealed anatomical variations of C5, C6 and C7 nerve roots in almost half of the patients examined, without negative block effectiveness. The addition of dexamethasone may prolong analgesia after single-shot interscalene and supraclavicular blocks. Insertion of brachial plexus perineural catheters using ultrasound guidance can be successful and provides better postoperative analgesia than single-shot blocks for up to 24 h postoperatively. Infraclavicular catheters provide superior analgesia when compared with supraclavicular catheters. Multiple-site injections of local offer no advantage over a single-site injection during an infraclavicular block. Ultrasound guidance compared with neurostimulation may reduce patient discomfort during axillary blocks compared with neurostimulation. Intra-epineural injections are common during an interscalene blockade, but the incidence of neurological injury remains low. There is an ongoing debate on the effectiveness and safety of ultrasound-guided intra-epineurial injections. SUMMARY Current literature suggests a reduction of the volume of local anesthetics used for ultrasound-guided upper extremity blockades. Dexamethasone may prolong duration of brachial plexus blocks and more frequent use of perineural catheters is encouraged. Controversy over intra-epineurial injections exists and requires additional large-scale studies.
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Gorsewski G, Dinse-Lambracht A, Tugtekin I, Gauss A. Ultraschallgesteuerte periphere Regionalanästhesie. Anaesthesist 2012; 61:711-21. [DOI: 10.1007/s00101-012-2045-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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50
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Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract 2012; 2012:560879. [PMID: 22761615 PMCID: PMC3385590 DOI: 10.1155/2012/560879] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 12/29/2022] Open
Abstract
A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.
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Affiliation(s)
- José Aguirre
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Alicia Del Moral
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Irina Cobo
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Alain Borgeat
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Stephan Blumenthal
- Department of Anesthesiology, Triemli Hospital, 8063 Zurich, Switzerland
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