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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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Paśnicki M, Król A, Kosson D, Kołacz M. The Safety of Peripheral Nerve Blocks: The Role of Triple Monitoring in Regional Anaesthesia, a Comprehensive Review. Healthcare (Basel) 2024; 12:769. [PMID: 38610191 PMCID: PMC11011500 DOI: 10.3390/healthcare12070769] [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: 01/31/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Regional anaesthesia, referred to as regional blocks, is one of the most frequently used methods of anaesthesia for surgery and for pain management. Local anaesthetic drug should be administered as close to the nerve as possible. If administered too far away, this may result in insufficient block. If it is administrated too close, severe nerve damage can occur. Neurostimulation techniques and ultrasound imaging have improved the effectiveness and safety of blockade, but the risk of nerve injury with permanent nerve disfunction has not been eliminated. Intraneural administration of a local anaesthetic damages the nerve mechanically by the needle and the high pressure generated by the drug inside the nerve. In many studies, injection pressure is described as significantly higher for unintended intraneural injections than for perineural ones. In recent years, the concept of combining techniques (neurostimulation + USG imaging + injection pressure monitoring) has emerged as a method increasing safety and efficiency in regional anaesthesia. This study focuses on the contribution of nerve identification methods to improve the safety of peripheral nerve blocks by reducing the risk of neural damage.
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Affiliation(s)
- Marek Paśnicki
- Department of Anaesthesiology and Intensive Care Education, Medical University of Warsaw, 4 Oczki Str., 02-005 Warsaw, Poland; (M.P.); (D.K.)
| | - Andrzej Król
- Department of Anaesthesia and Chronic Pain Service, St George’s University Hospital, Blackshaw Road Tooting, London SW17 0QT, UK
| | - Dariusz Kosson
- Department of Anaesthesiology and Intensive Care Education, Medical University of Warsaw, 4 Oczki Str., 02-005 Warsaw, Poland; (M.P.); (D.K.)
| | - Marcin Kołacz
- 1st Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, 4 Lindleya Str., 02-005 Warsaw, Poland;
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Lemke E, Johnston DF, Behrens MB, Seering MS, McConnell BM, Swaran Singh TS, Sondekoppam RV. Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance. Reg Anesth Pain Med 2024; 49:122-132. [PMID: 37940348 DOI: 10.1136/rapm-2023-104855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed. OBJECTIVE In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance. EVIDENCE REVIEW A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion. FINDINGS The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block. CONCLUSIONS Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.
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Affiliation(s)
- Ethan Lemke
- Emergency Medicine, University of Michigan Health-West, Wyoming, Michigan, USA
| | - David F Johnston
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Matthew B Behrens
- Department of Emergency Medicine, Kent Hospital, Warwick, Rhode Island, USA
| | - Melinda S Seering
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
| | - Brie M McConnell
- Davis Library, University of Waterloo, Waterloo, Ontario, Canada
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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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Koh K, Tatsuki O, Sakuraba S, Yamazaki S, Yako H, Omae T. Neuropathies Following an Ultrasound-Guided Axillary Brachial Plexus Block. Local Reg Anesth 2023; 16:123-132. [PMID: 37693952 PMCID: PMC10488563 DOI: 10.2147/lra.s426515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose Ultrasound-guided brachial plexus block (UGBPB) has interscalene, supraclavicular, infraclavicular, and axillary approaches. The axillary block is considered to be the safest and with fewer adverse events compared to the interscalene (eg, phrenic nerve block, spinal cord or vertebral artery puncture) and supraclavicular (eg, pneumothorax). However, with regard to postoperative neurological symptoms (PONS), it is controversial whether its incidence after an axillary block was higher than that after non-axillary approaches". In this study, we investigated whether the incidence of a neuropathy after an axillary block was higher than that after non-axillary approaches. Patients and Methods This was a single-center, retrospective cohort study. All UGBPBs were performed under general anesthesia between January 2014 and March 2020. The outcomes included the overall incidence of PONS and neuropathies for axillary and non-axillary approaches. The etiology, symptoms, and outcomes of patients were investigated. Results Of the 992 patients, 143 (14%) and 849 (86%) were subjected to axillary and non-axillary approaches, respectively. Among 19 cases (19.2:1000; 95% confidence interval [CI], 18.2-20.1) of PONS, four (4.0:1000; 95% CI, 3.8-4.2) were neuropathies attributed to the UGBPB, three (21.0:1000; 95% CI, 18.1-23.8) to the axillary and one (2.8:1000; 95% CI, 2.6-3.1) to non-axillary approaches. The incidence of neuropathies after an axillary block was significantly higher than that after non-axillary approaches (P = 0.005). Conclusion The incidence of neuropathies after US-guided axillary block under general anesthesia was significantly higher than that after non-axillary approaches.
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Affiliation(s)
- Keito Koh
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Onishi Tatsuki
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sonoko Sakuraba
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sho Yamazaki
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hajime Yako
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Takeshi Omae
- Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
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Kaushik P, Hayaran N, Goel I. Multimodal Approach in Minimizing Transient Neurological Complications Following Single Shot Brachial Plexus Block: A Prospective Observational Study. Cureus 2023; 15:e35667. [PMID: 36875251 PMCID: PMC9978168 DOI: 10.7759/cureus.35667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
PURPOSE The aim of the study was to assess the benefit of a using multimodal approach, including injection pressure monitoring (IPM) and different techniques of nerve localization, with respect to complications following single-shot brachial plexus block (SSBPB). METHODS In this study, 238 adults (132 males and 106 females) undergoing upper-limb surgeries under peripheral nerve block (PNB) were evaluated. Of these, 198 patients were given supraclavicular block, and 40 patients received interscalene block using either ultrasound (USG) and peripheral nerve stimulation (PNS) or PNS alone. Injection pressure monitoring was used in 216 patients. RESULTS Transient neurological deficit (TND) was observed in six out of 198 patients where USG and NS were used along with IPM as opposed to 12 out of 18 patients without IPM (p<0.0001). In patients where only PNS was used, transient neurological deficit (TND) was seen in six out of 18 patients with IPM as opposed to all the patients (n=4) without IPM (p<0.02). Among the patients where injection pressure was monitored, six out of 198 patients developed TND when both USG and NS were used, compared to six out of 18 patients where only PNS was used (p<0.007). CONCLUSION Use of injection pressure monitoring along with different nerve localization techniques results in fewer transient neurological deficits.
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Affiliation(s)
- Parul Kaushik
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Nitin Hayaran
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Ishan Goel
- Radiology, Lady Hardinge Medical College, New Delhi, IND
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Lin SZ, Chen L, Tang YJ, Zheng CJ, Ke P, Chen MN, Wu HX, Chen Y, Qiu LC, Wu XD, Zeng K. Establishment of ultrasound-guided stellate ganglion block in rats. Front Neurosci 2023; 16:1061767. [PMID: 36711146 PMCID: PMC9877532 DOI: 10.3389/fnins.2022.1061767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/23/2022] [Indexed: 01/15/2023] Open
Abstract
Background A novel protocol for accurate stellate ganglion block under ultrasound guidance was designed in rats. This technique raises the success rate of stellate ganglion block and reduces the incidence of brachial plexus and vagus nerve block. Methods Fifty-six Sprague-Dawley were randomly divided into an ultrasound-guided group (n = 28) and a blind technique group (n = 28). The rats in the blind technique group were injected with 1.5% lidocaine mixed with methylene blue after signs of brachial plexus stimulation were elicited. The lateral side of the cephalic brachial vein was located under the first rib, where lidocaine was injected into the rats in the ultrasound-guided group. The up-and-down sequential method of Dixon was used to determine the minimum effective volume for stellate ganglion block in rats. Furthermore, we calculated the required operative duration of the two methods and observed the difference in the lidocaine diffusion range between the two groups. Results The minimum effective volume for stellate ganglion block in the ultrasound-guided group was 0.040 ml, and the 95% CI was 0.026-0.052 ml. In the blind technique group, the minimum effective volume was 0.639 ml, and the 95% CI was 0.490-0.733 ml. Within the 95% CI of the lowest effective volume, the incidence of brachial plexus block as a complication of stellate ganglion block under ultrasound guidance was 10.00%. Conclusion Stellate ganglion block under ultrasound guidance is more accurate than blind detection, which the incidence of complications of stellate ganglion block under ultrasound guidance was significantly lower than under blind detection; the rate of methylene blue staining in the vagus nerve was significantly lower under ultrasound guidance.
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Affiliation(s)
- Shi-zhu Lin
- Department of Anesthesiology, Anesthesiology Research Institute, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lu Chen
- Department of Anesthesiology, Anesthesiology Research Institute, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yi-jie Tang
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Cheng-jie Zheng
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Peng Ke
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Meng-nan Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Hai-xing Wu
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Yu Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Liang-cheng Qiu
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiao-dan Wu
- Department of Anesthesiology, Fujian Provincial Hospital, Fujian Provincial Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China,*Correspondence: Xiao-dan Wu,
| | - Kai Zeng
- Department of Anesthesiology, Anesthesiology Research Institute, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Kai Zeng,
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Goffin P, Mejia J, Prats-Galino A, Morales L, Panzeri M, Sala-Blanch X. Ultrasound is better than injection pressure monitoring detecting the low-volume intraneural injection. Reg Anesth Pain Med 2022; 47:rapm-2022-103759. [PMID: 35944936 DOI: 10.1136/rapm-2022-103759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/27/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Inadvertent intraneural injection is not infrequent during peripheral nerve blocks. For this reason, injection pressure monitoring has been suggested as a safeguard method that warns the clinician of a potentially hazardous needle tip location. However, doubts remain whether it is superior to the sonographic nerve swelling in terms of earlier detection of the intraneural injection. METHODS An observational cadaveric study was designed to assess injection pressures during an ultrasound-guided intraneural injection of the median nerve. We hypothesized that the evidence of nerve swelling occurred prior to an elevated injection pressure (>15 pound per square inch) measured with a portable in-line monitor. 33 ultrasound-guided intraneural injections of 11 median nerves from unembalmed human cadavers were performed at proximal, mid and distal forearm. 1 mL of a mixture of local anesthetic and methylene blue was injected intraneurally at a rate of 10 mL/min. Following injections, specimens were dissected to assess spread location. Video recordings of the procedures including ultrasound images were blindly analyzed to evaluate nerve swelling and injection pressures. RESULTS 31 injections were considered for analysis (two were excluded due to uncertainty regarding needle tip position). >15 pound per square inch was reached in six injections (19%) following a median injected volume of 0.6 mL. Nerve swelling was evident in all 31 injections (100%) with a median injected volume of 0.4 mL. On dissection, spread location was confirmed intraneural in all injections. DISCUSSION Ultrasound is a more sensitive and earlier indicator of the low-volume intraneural injection than injection pressure monitoring.
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Affiliation(s)
- Pierre Goffin
- Masters Degree in Advanced Medical Skills. Regional Anesthesia Based on Human Anatomy, University of Barcelona, Barcelona, Barcelona, Spain
- Anesthesia and Intensive Care, MontLégia Hospital, Groupe Santé CHC, Liège, Belgium
| | - Jorge Mejia
- Human Anatomy and Embryology, Universitat de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Lorena Morales
- Masters Degree in Advanced Medical Skills. Regional Anesthesia Based on Human Anatomy, University of Barcelona, Barcelona, Barcelona, Spain
| | - Miriam Panzeri
- Human Anatomy and Embryology, Universitat de Barcelona, Barcelona, Spain
| | - Xavier Sala-Blanch
- Human Anatomy and Embryology, Universitat de Barcelona, Barcelona, Spain
- Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
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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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Wu Z, Wang Y. Development of Guidance Techniques for Regional Anesthesia: Past, Present and Future. J Pain Res 2021; 14:1631-1641. [PMID: 34135627 PMCID: PMC8200162 DOI: 10.2147/jpr.s316743] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/30/2021] [Indexed: 12/24/2022] Open
Abstract
Regional anesthesia has been widely used in clinical practice. Over the past 30 years, various guidance techniques have been developed for regional anesthesia ranging from paresthesia progressing to neurostimulation and currently ultrasound guidance. Especially, the use of point-of-care ultrasound greatly enhances the success rate of regional anesthesia. However, the poor imaging quality of ultrasound in patients with obesity, fat infiltration, etc., limits the use of ultrasound. The combined use of ultrasound with neurostimulator, electromyography, pressure monitoring, etc. is advocated in order to facilitate regional anesthesia in this cohort of patients. The accumulated evidence has shown that the ultrasound combined with other techniques (UCOT) can help to solve the difficulties of puncture location caused by obesity, anatomical variation, and other factors when using ultrasound guidance alone. In recent years, with the development of medical image fusion and medical image artificial intelligence identification technology, guidance techniques for regional anesthesia have advanced considerably. To understand the advantages and disadvantages of the various guidance techniques for regional anesthesia developed in recent years and to guide their rational clinical application, this paper reviews these techniques, describing the progression from the early use of paresthesia to the latest UCOT, as well as the latest research on UCOT, and the prospects for the development of new guidance techniques for regional anesthesia.
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Affiliation(s)
- Zehao Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
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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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Gadsden JC. The role of peripheral nerve stimulation in the era of ultrasound-guided regional anaesthesia. Anaesthesia 2021; 76 Suppl 1:65-73. [PMID: 33426665 DOI: 10.1111/anae.15257] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
Abstract
With the widespread use of ultrasound for localising nerves during peripheral nerve blockade, the value of electrical nerve stimulation of evoked motor responses has been questioned. Studies continue to show that, compared with nerve stimulation, ultrasound guidance alone leads to: significantly improved block success; decreased need for rescue analgesia; decreased procedural pain; and lower rates of vascular puncture. Nerve stimulation combined with ultrasound does also not appear to improve block success rates, apart from those blocks where the nerves are challenging to view, such as the obturator nerve. The role of nerve stimulation has changed in the last 15 years from a technique to locate nerves to that of an adjunct to ultrasound. Nerve stimulation can serve as a monitor against needle-nerve contact and may be useful in avoiding nerves that are in the needle trajectory during specific ultrasound guided techniques. Nerve stimulation is also a useful adjunct in teaching novices ultrasound-guided regional anaesthesia, especially when the position and or appearance of nerves may be variable. In this review, the changing role of nerve stimulation in contemporary regional anaesthetic practice is presented and discussed.
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Affiliation(s)
- J C Gadsden
- Department of Anaesthesiology, Duke University, Durham, NC, USA
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18
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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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19
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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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20
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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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21
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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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22
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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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23
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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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24
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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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25
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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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26
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Tran DQ, Salinas FV, Benzon HT, Neal JM. Lower extremity regional anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2019; 44:rapm-2018-000019. [PMID: 30635506 DOI: 10.1136/rapm-2018-000019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022]
Abstract
The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.
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Affiliation(s)
- De Q Tran
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, Swedish Medical Center, Seattle, Washington, USA
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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Weisman RS, Bhavsar NP, Schuster KA, Gebhard RE. Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade. Reg Anesth Pain Med 2019; 44:86-90. [DOI: 10.1136/rapm-2018-000026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 11/03/2022]
Abstract
Background and ObjectivesThe exact mechanism of peripheral nerve blocks causing/leading to nerve injury remains controversial. Evidence from animal experiments suggests that intrafascicular injection resulting in high injection pressure has the potential to rupture nerve fascicles and may consequently cause permanent nerve injury and neurological deficits. The B-Smart (BS) in-line manometer and the CompuFlo (CF) computerized injection pump technology are two modalities used for monitoring pressure during regional anesthesia. This study sought to explore the accuracy of these two technologies in measuring needle-tip pressures in a simulated environment.MethodsIn seven simulated needle–syringe combinations, the BS and the CF devices were connected in series through a closed system and attached to a digital manometer at the tip of various needles. The pressures were evaluated in three trials per needle-syringe combination. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (F1 Score) were determined for each needle type and overall.ResultsFor pressures ≥15 psi and ≥20 psi, respectively, the CF device demonstrated a sensitivity of 100%, 100%; specificity of 96%, 98%; positive predictive value 93%, 93%; and negative predictive value of 100%, 100%. The BS device demonstrated a sensitivity of 60%, 100%; specificity of 99%, 95%; positive predictive value of 96%, 85%; and negative predictive value of 85%, 100%. Accuracy, as measured by the F1 Score, for detecting a pressure of ≥15 psi was 0.96 for the CF and 0.74 for the BS.ConclusionsFuture research is needed to explore in-vivo performance and evaluate whether either of these devices can impact on clinical outcomes.
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28
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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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Emelife PI, Eng MR, Menard BL, Myers AS, Cornett EM, Urman RD, Kaye AD. Adjunct medications for peripheral and neuraxial anesthesia. Best Pract Res Clin Anaesthesiol 2018; 32:83-99. [PMID: 30322466 DOI: 10.1016/j.bpa.2018.06.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Regional and neuraxial anesthesia can provide a safer perioperative experience, greater satisfaction, reduced opioid consumption, and reduction of pain, while minimizing side effects. Ultrasound technology has aided clinicians in depositing local anesthetic medication in precise proximity to targeted peripheral nerves. There are a plethora of adjuvants that have been utilized to prolong local anesthetic actions and enhance effects in peripheral nerve blocks. This manuscript describes the current state of the use of adjuncts, e.g., dexmedetomidine, dexamethasone, clonidine, epinephrine, etc., in regional anesthesia. Additionally, evidence behind dosing and block prolongation is summarized along with patient outcomes, adverse effects, and future directions.
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Affiliation(s)
- Patrick Ifesinachi Emelife
- Department of Anesthesiology, LSU Health Sciences Center, Room 653, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Matthew R Eng
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Bethany L Menard
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
| | - Andrew S Myers
- LSU Health Sciences Center, 433 Bolivar St., New Orleans, LA, 70112, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 653, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
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Pichamuthu JE, Maiti S, Gan MG, Verdecchia NM, Orebaugh SL, Vorp DA. Mechanics of anesthetic needle penetration into human sciatic nerve. J Biomech 2018; 74:92-97. [PMID: 29728269 DOI: 10.1016/j.jbiomech.2018.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 04/06/2018] [Accepted: 04/14/2018] [Indexed: 10/17/2022]
Abstract
Nerve blocks are frequently performed by anesthesiologists to control pain. For sciatic nerve blocks, the optimal placement of the needle tip between its paraneural sheath and epineurial covering is challenging, even under ultrasound guidance, and frequently results in nerve puncture. We performed needle penetration tests on cadaveric isolated paraneural sheath (IPS), isolated nerve (IN), and the nerve with overlying paraneural sheath (NPS), and quantified puncture force requirement and fracture toughness of these specimens to assess their role in determining the clinical risk of nerve puncture. We found that puncture force (123 ± 17 mN) and fracture toughness (45.48 ± 9.72 J m-2) of IPS was significantly lower than those for NPS (1440 ± 161 mN and 1317.46 ± 212.45 Jm-2, respectively), suggesting that it is not possible to push the tip of the block needle through the paraneural sheath only, without pushing it into the nerve directly, when the sheath is lying directly over the nerve. Results of this study provide a physical basis for tangential placement of the needle as the ideal situation for local anesthetic deposition, as it allows for the penetration of the sheath along the edge of the nerve without entering the epineurium.
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Affiliation(s)
- Joseph E Pichamuthu
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, Pittsburgh, PA, United States; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, PA, United States
| | - Spandan Maiti
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Maria G Gan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nicole M Verdecchia
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Steven L Orebaugh
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - David A Vorp
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, Pittsburgh, PA, United States; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, PA, United States; Departments of Cardiothoracic Surgery, Surgery, and Chemical & Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA, United States; Clinical & Translational Sciences Institute, University of Pittsburgh, Pittsburgh, PA, United States.
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Wahal C, Kumar A, Pyati S. Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes. Indian J Anaesth 2018; 62:94-102. [PMID: 29491513 PMCID: PMC5827494 DOI: 10.4103/ija.ija_433_17] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.
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Affiliation(s)
- Christopher Wahal
- Department of Anesthesiology, Division of Regional Anesthesia and Pain Management, Veterans Affairs Medical Center, Duke University School of Medicine, North Carolina, USA
| | - Amanda Kumar
- Department of Anesthesiology, Division of Regional Anesthesia and Pain Management, Veterans Affairs Medical Center, Duke University School of Medicine, North Carolina, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Division of Regional Anesthesia and Pain Management, Veterans Affairs Medical Center, Duke University School of Medicine, North Carolina, USA
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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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Hewson DW, Bedforth NM, Hardman JG. Peripheral nerve injury arising in anaesthesia practice. Anaesthesia 2018; 73 Suppl 1:51-60. [DOI: 10.1111/anae.14140] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- D. W. Hewson
- Department of Anaesthesia; Nottingham University Hospitals NHS Trust; Nottingham UK
| | - N. M. Bedforth
- Department of Anaesthesia; Nottingham University Hospitals NHS Trust; Nottingham UK
| | - J. G. Hardman
- Anaesthesia and Critical Care; Division of Clinical Neuroscience; School of Medicine; University of Nottingham; UK
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Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8284363. [PMID: 29226150 PMCID: PMC5684553 DOI: 10.1155/2017/8284363] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/19/2017] [Accepted: 06/28/2017] [Indexed: 02/02/2023]
Abstract
Purpose of Review Transversus abdominis plane (TAP) block is a regional technique for analgesia of the anterolateral abdominal wall. This review highlights the nomenclature system and recent advances in TAP block techniques and proposes directions for future research. Recent Findings Ultrasound guidance is now considered the gold standard in TAP blocks. It is easy to acquire ultrasound images; it can be used in many surgeries involving the anterolateral abdominal wall. However, the efficacy of ultrasound-guided TAP blocks is not consistent, which might be due to the use of different approaches. The choice of technique influences the involved area and block duration. To investigate the actual analgesic effects of TAP blocks, we unified the nomenclature system and clarified the definition of each technique. Although a single-shot TAP block is limited in duration, it is still the candidate of the analgesic standard for abdominal wall surgery because the use of the catheter technique and liposomal bupivacaine may overcome this limitation. Summary Ultrasound-guided TAP blocks are commonly used. With the unified nomenclature and the development of catheter technique and/or liposomal local anesthetics, TAP blocks can be applied more appropriately to achieve better pain control.
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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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Fielmuth S, Szalata M, Sievert H, Beier D, Rehberg S, Hahnenkamp K, Mauermann K, Meissner K. Electric Nerve Stimulation Does Not Correctly Predict Needle-Nerve Distance and Potential Local Anesthetic Spread for Interscalene Brachial Plexus Blockade. Anesth Analg 2017; 125:632-634. [DOI: 10.1213/ane.0000000000001982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Intermittent Bolus Injection Via Peripheral Nerve Catheters May Exceed Occlusion Pressure Limit of an Ambulatory Infusion Pump: An In Vitro Study. Reg Anesth Pain Med 2017. [PMID: 28632675 DOI: 10.1097/aap.0000000000000625] [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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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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Addition of Liposome Bupivacaine to Bupivacaine HCl Versus Bupivacaine HCl Alone for Interscalene Brachial Plexus Block in Patients Having Major Shoulder Surgery. Reg Anesth Pain Med 2017; 42:334-341. [DOI: 10.1097/aap.0000000000000560] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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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Bang SU, Kim DJ, Bae JH, Chung K, Kim Y. Minimum effective local anesthetic volume for surgical anesthesia by subparaneural, ultrasound-guided popliteal sciatic nerve block: A prospective dose-finding study. Medicine (Baltimore) 2016; 95:e4652. [PMID: 27559966 PMCID: PMC5400333 DOI: 10.1097/md.0000000000004652] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Because of its rapid onset time, recent years have seen an increase in the use of ultrasound (US)-guided popliteal sciatic nerve block (PSNB) via subparaneural injection for induction of surgical anesthesia. Moreover, in below-knee surgery, combined blocks, as opposed to sciatic nerve block alone, have become more common. These combined blocks often require a large volume of local anesthetic (LA), thus increasing the risk of local-anesthetic systemic toxicity (LAST). Thus, to decrease the risk of LAST, it is important to know the minimum effective volume (MEV) required for an adequate block. We, therefore, aimed to determine the MEV of ropivacaine 0.75% for induction of surgical anesthesia by the method of US-guided popliteal sciatic nerve block via subparaneural injection.Thirty patients underwent a US-guided PSNB with ropivacaine 0.75% at a 20-mL starting volume. Using a step-up/step-down method, we determined injection volumes for consecutive patients from the preceding patient's outcome. When an effective block was achieved within 40 minutes after injection, the next patient's volume was decreased by 2 mL. If the block failed, the next patient's volume was increased by 2 mL. The sensory and motor blockade was graded according to a 4-point scale. The block was considered a success if a combination of anesthesia and paresis (a score of 3 for both the sensory and motor nerves) was achieved within 40 minutes. The primary outcome measure was the MEV resulting in a successful subparaneural block of the sciatic nerve in 50% of patients (MEV50). Additionally, the data were processed with a probit regression analysis to determine the volume required to produce a complete sciatic nerve block in 90% of subjects (ED90).The MEV50 of 0.75% ropivacaine is 6.14 mL (95% confidence interval, 4.33-7.94 mL). The ED90 by probit analysis for a subparaneural injection was 8.9 mL (95% CI, 7.09-21.75 mL).The 6.14-mL MEV50 of ropivacaine 0.75% represents a 71% reduction in volume compared with neurostimulation techniques and a 14.7% reduction in volume compared with US-guided PSNB using the alternative perineural injection technique.
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Affiliation(s)
- Seung Uk Bang
- Department of Anesthesiology and Pain Medicine, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Ju Kim
- Department of Surgery, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Jin Ho Bae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Kyudon Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
| | - Yeesuk Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
- Correspondence: Yeesuk Kim, 327, Sosa-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea (e-mail: )
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48
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Affiliation(s)
- A M Adams
- Lancashire Teaching Hospitals NHS Trust, Preston, UK.
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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; 116:574-5. [DOI: 10.1093/bja/aev459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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50
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