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Ameta N, Ramkiran S, Vivekanand D, Honwad M, Jaiswal A, Gupta MK. Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study. J Anaesthesiol Clin Pharmacol 2023; 39:488-496. [PMID: 38025564 PMCID: PMC10661648 DOI: 10.4103/joacp.joacp_411_21] [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: 08/13/2022] [Revised: 08/15/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery. Material and Methods This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block. Results The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable. Conclusion Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.
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Affiliation(s)
- Nihar Ameta
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Seshadri Ramkiran
- Department of Onco-Anesthesiology, HCG Cancer Centre, Kalinga Rao Road, Sampangiram Nagar, Bengaluru, India
| | | | - Manish Honwad
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Alok Jaiswal
- Department of Anaesthesia, 150 General Hospital, C/O 99 APO, Meerut, Uttar Pradesh, India
| | - Manoj Kumar Gupta
- Station Health Organisation, Meerut Cantt, Meerut, Uttar Pradesh, India
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Delgado OBD, Louro LF, Rocchigiani G, Verin R, Humphreys W, Senior M, Campagna I. Ultrasound-guided erector spinae plane block in horses: a cadaver study. Vet Anaesth Analg 2021; 48:577-584. [PMID: 33934991 DOI: 10.1016/j.vaa.2020.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/02/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To describe dye distribution and spinal nerve involvement after a simulated erector spinae plane (ESP) block performed on fresh equine cadavers. STUDY DESIGN Experimental cadaver study. ANIMALS A group of 11 adult equine cadavers. METHODS The spinal region surrounding the sixteenth thoracic vertebra (Th16) of one cadaver was removed and underwent magnetic resonance imaging. In 10 adult equine cadavers [body weight, 549 ± 58 kg (mean ± standard deviation)], 0.2 mL kg-1 of a 50:1 2% lidocaine/dye solution was injected bilaterally (n = 20 injections) into the fascial plane between the transverse process of Th16 and the erector spinae muscles. An in-plane ultrasound-guided technique with a convex transducer was used to guide injection. Dissection was performed immediately following injection. The craniocaudal and lateral extent of dye distribution was measured (cm) and the number of vertebral bodies involved were counted (n = 20). Abdominal and thoracic cavities as well as the epidural space were also examined for presence of dye (yes/no) (n = 20). Further dissection was performed to evaluate if staining of the dorsal and ventral rami of the spinal nerves and sympathetic chain occurred (n = 14). RESULTS The thoracolumbar fascia was stained in 17/20 (85%) injections and three injections terminated intramuscularly. Multisegmental staining of the dorsal rami was observed in the 14 injections in which staining was evaluated. Ventral rami staining was observed in 3/14 injections where staining was evaluated. Epidural migration was observed in 4/20 (20%) injections. No evidence of dye was found in the thoracic and abdominal cavities or on the sympathetic chain. CONCLUSIONS AND CLINICAL RELEVANCE The ESP block may prove beneficial to desensitize structures innervated by the dorsal rami of the thoracic spinal nerves. Further investigation is necessary to evaluate complications caused by epidural contamination.
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Affiliation(s)
| | - Luis Filipe Louro
- Department of Small Animal Clinical Science, University of Liverpool, Liverpool, UK
| | - Guido Rocchigiani
- Department of Veterinary Pathology and Public Health, University of Liverpool, Liverpool, UK
| | - Ranieri Verin
- Department of Veterinary Pathology and Public Health, University of Liverpool, Liverpool, UK; Department of Comparative Biomedicine and Food Science, University of Padova, Padova, Italy
| | - William Humphreys
- Department of Small Animal Clinical Science, University of Liverpool, Liverpool, UK
| | - Mark Senior
- Department of Equine Clinical Science, University of Liverpool, Liverpool, UK
| | - Ivo Campagna
- Department of Small Animal Clinical Science, University of Liverpool, Liverpool, UK; Department of Equine Clinical Science, University of Liverpool, Liverpool, UK
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Thomson ACS, Portela DA, Romano M, Otero PE. Evaluation of the effect of ultrasound guidance on the accuracy of intercostal nerve injection: a canine cadaveric study. Vet Anaesth Analg 2020; 48:256-263. [PMID: 33583728 DOI: 10.1016/j.vaa.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To develop an ultrasound-guided approach to intercostal nerve injection and to compare the success rate of intercostal nerve injections using blind or ultrasound-guided technique in canine cadavers. STUDY DESIGN Prospective, randomized, descriptive, experimental anatomic study. ANIMALS A total of 14 mid-sized adult canine cadavers. METHODS Ultrasound landmarks were identified by dissection of four cadavers and used to develop an ultrasound-guided technique. The remaining 10 cadavers were randomly assigned to blind (five cadavers) or ultrasound-guided (five cadavers) injections of the third to the ninth intercostal nerves bilaterally with 0.03 mL kg-1 of colorant per injection. The target for intercostal injections was the caudal border of the respective rib, between the internal intercostal membrane and the parietal pleura. Additionally, displacement of the parietal pleura without visible intramuscular distribution was considered the end point for ultrasound-guided injections. For each cadaver, a practitioner in training performed the blocks on one hemithorax, while an experienced practitioner performed the blocks on the opposite hemithorax. Injections were considered successful if ≥1 cm of the target nerve was stained with colorant upon dissection. Success rates and length of nerve staining were analyzed with Fisher's exact and t tests, respectively. Data were considered statistically different with p < 0.05. RESULTS Success rates of blind and ultrasound-guided technique were 57.1% and 91.4%, respectively (p < 0.0001). The length of intercostal nerve staining was 3.1 ± 1.2 cm and 3.6 ± 1.0 cm using blind and ultrasound-guided techniques, respectively (p = 0.02). No differences were observed between the two practitioners for blind (p = 0.33) and ultrasound-guided techniques (p = 0.67). CONCLUSIONS AND CLINICAL RELEVANCE Ultrasound guidance improves the accuracy of intercostal nerve injections when compared with blind technique, independently of the level of expertise in regional anesthesia.
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Affiliation(s)
- Alexander C S Thomson
- Department of Comparative Diagnostic and Population Medicine, University of Florida College of Veterinary Medicine, Gainesville, FL, USA
| | - Diego A Portela
- Department of Comparative Diagnostic and Population Medicine, University of Florida College of Veterinary Medicine, Gainesville, FL, USA.
| | - Marta Romano
- Department of Comparative Diagnostic and Population Medicine, University of Florida College of Veterinary Medicine, Gainesville, FL, USA
| | - Pablo E Otero
- Department of Anesthesiology and Pain Management, Facultad de Ciencias Veterinarias, Universidad de Buenos Aires, Buenos Aires, Argentina
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de Miguel Garcia C, Whyte M, St James M, Ferreira TH. Effect of contrast and local anesthetic on dye spread following transversus abdominis plane injection in dog cadavers. Vet Anaesth Analg 2020; 47:391-395. [DOI: 10.1016/j.vaa.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 11/25/2022]
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Efficacy of greater auricular and auriculotemporal nerve blocks performed in rabbits. Vet Anaesth Analg 2020; 47:567-573. [PMID: 32336591 DOI: 10.1016/j.vaa.2020.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy, duration and safety of greater auricular and auriculotemporal nerve blocks in rabbits. STUDY DESIGN Prospective, randomized, crossover, experimental study. ANIMALS A total of 11 healthy adult Dutch-belted rabbits. METHODS The rabbits underwent general anesthesia and injections of the greater auricular and auriculotemporal nerves using either bupivacaine (0.3 mL kg-1, 0.5%) or the same volume of saline. After anesthesia, the efficacy and duration of nerve blocks were assessed using analgesiometry forceps on the pinna and cotton-tipped applicators within the vertical ear canal. Rabbits were monitored for abnormal carriage of the ear and auriculopalpebral nerve block of the ipsilateral eye. Body weight, food intake, fecal output and fecal pellet diameter were measured daily for 6 days after the nerve blocks were performed and compared with baseline to assess short-term effects. RESULTS The greater auricular nerve was successfully blocked in 12/16 (75%) ears for mean ± standard deviation duration of 88 ± 52 minutes. In successfully blocked ears, altered ear position was noted in five/16 (31%) cases. The auriculotemporal nerve was blocked in one/16 ears for 120 minutes. The auriculopalpebral nerve was inadvertently blocked in three/16 ears. Food intake and fecal output decreased significantly during the treatment day but returned to pretreatment values after 24 hours. There was no change in body weight or fecal pellet diameter for either treatment. CONCLUSIONS AND CLINICAL RELEVANCE The results suggest that duration of the greater auricular nerve block with 0.5% bupivacaine was short-lived in the live rabbit. Auriculotemporal nerve block was only achieved in one ear; therefore, further studies are warranted to evaluate the contribution of these blocks in the pain management of rabbits undergoing auricular surgery.
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Injection techniques for auricular nerve blocks in the rabbit cadaver. Vet Anaesth Analg 2019; 47:274-279. [PMID: 32029354 DOI: 10.1016/j.vaa.2019.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/28/2019] [Accepted: 11/26/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe the landmarks for localization and to determine the methodology and volume of methylene blue dye to adequately stain the auricular nerves in rabbit cadavers. STUDY DESIGN Prospective, randomized, cadaveric study. ANIMALS A total of 26 rabbit cadavers (Dutch-Belted and New Zealand White breeds). METHODS Part I: anatomical dissections were performed to identify the sensory auricular nerves and to establish the ideal injection approach and volume of dye required for nerve staining. Part II: a single injection technique using 0.1 mL kg-1 dye was evaluated for staining the greater auricular nerve and two techniques (perpendicular and angled needle approaches) using 0.075 mL kg-1 dye were evaluated for the auriculotemporal nerve. Dye spread was evaluated through cadaveric dissections and nerve staining graded using a 0-2 point scale. Injections were considered successful if the nerve was stained circumferentially. Cadavers were assessed for staining of the mandibular nerve owing to the close proximity to the auriculotemporal nerve. Fisher's exact test and mixed effects logistic regression model were used for statistical analysis. RESULTS The greater auricular nerve was stained in 24/27 (88.9%) injections. The auriculotemporal nerve was stained in 7/12 injections (58.3%) with the perpendicular needle approach; staining success increased to 80% (12/15 injections) with the angled needle approach; however, this difference was not statistically significant (p = 0.228). Mandibular nerve staining occurred on seven auriculotemporal injections with no statistically significant difference in the incidence of nerve staining between techniques. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that the auricular nerves in rabbit cadavers can be successfully located and stained using anatomic landmarks and the described injection techniques.
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Ferreira TH, St James M, Schroeder CA, Hershberger-Braker KL, Teixeira LBC, Schroeder KM. Description of an ultrasound-guided erector spinae plane block and the spread of dye in dog cadavers. Vet Anaesth Analg 2019; 46:516-522. [PMID: 31029460 DOI: 10.1016/j.vaa.2019.03.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To describe a technique to perform an ultrasound-guided erector spinae plane (ESP) block and determine the distribution and potential complications after injection of two volumes of methylene blue in dog cadavers. STUDY DESIGN Prospective experimental cadaveric study. ANIMALS A total of eight dog cadavers weighing 9.3 ± 1.9 kg. METHODS Ultrasound-guided injections dorsal to the transverse process and ventral to the erector spinae muscles aimed at the fifth thoracic transverse process were performed bilaterally in each dog using 0.5 and 1.0 mL kg-1 dye solution [low volume (LV) and high volume (HV) treatments, respectively]. Treatments were randomly assigned to the right or left side of each dog, resulting in a total of 16 injections. Anatomical dissections determined dye spread characteristics, including epaxial muscles spread, staining of spinal nerves, dorsal rami, ventral rami (intercostal nerves) and sympathetic trunk spread. Staining indicating potential complications (epidural, mediastinal and intrapleural spread) was recorded. RESULTS There was complete staining of at least one dorsal ramus following all injections. A more extensive spread was observed along the muscles in the HV compared with LV (p = 0.036). No significant difference between multisegmental dorsal rami spread (six out of eight injections in each treatment) was noted. Out of 16 injections, one in LV treatment resulted in multisegmental spinal nerve staining and one in HV treatment resulted in ventral ramus (intercostal nerve) staining. Use of anatomic landmarks resulted in inaccurate identification of the fifth transverse process in at least six out of 16 injections (38%). No sympathetic trunk, epidural, mediastinal or intrapleural staining was observed. CONCLUSIONS AND CLINICAL RELEVANCE Ultrasound-guided ESP injections resulted in extensive staining along the epaxial muscles, as well as staining of the dorsal rami in all dogs. The incidence of dorsal rami mutisegmental spread was the same in both treatments.
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Affiliation(s)
- Tatiana H Ferreira
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA.
| | - Mariko St James
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Carrie A Schroeder
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Karen L Hershberger-Braker
- Department of Pathobiological Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Comparative Biosciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Leandro B C Teixeira
- Department of Pathobiological Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Ferreira TH, Teixeira LB, Schroeder CA, de Miguel Garcia C, Schroeder KM. Description of an ultrasound-guided thoracic paravertebral block technique and the spread of dye in dog cadavers. Vet Anaesth Analg 2018; 45:811-819. [DOI: 10.1016/j.vaa.2018.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 12/26/2022]
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Luyet C, Herrmann G, Ross S, Vogt A, Greif R, Moriggl B, Eichenberger U. Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go? Br J Anaesth 2010; 106:246-54. [PMID: 21112880 DOI: 10.1093/bja/aeq309] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Paravertebral regional anaesthesia is used to treat pain after several surgical procedures. This study aimed to improve on our first published ultrasound-guided approach to the paravertebral space (PVS) and to investigate a possible discrepancy between the needle, catheter, and contrast dye position. METHODS In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches combined with loss of resistance (LOR) and after an interim analysis performed 36 novel, pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was controlled by a first computed tomography (CT) scan. After placement of the catheters, the tips were assessed by a second CT and the spread of injected contrast dye was assessed by further CT scans. The part of the PVS near the intervertebral foramen was defined as the primary target to reach. RESULTS The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34 (94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed: three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected in the epidural space. In two cases, insertion of the catheter was not possible. In cases with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (sd)] vertebral segments. CONCLUSIONS Our new PUSG technique has a high success rate for paravertebral needle placement. Although needles were correctly positioned, catheters were usually found distant from the needle-tip position.
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Affiliation(s)
- C Luyet
- University Department of Anaesthesiology and Pain Therapy, University Hospital and University of Bern, Bern, Switzerland
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Paraskeuopoulos T, Saranteas T, Kouladouros K, Krepi H, Nakou M, Kostopanagiotou G, Anagnostopoulou S. Thoracic paravertebral spread using two different ultrasound-guided intercostal injection techniques in human cadavers. Clin Anat 2010; 23:840-7. [DOI: 10.1002/ca.21021] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 05/26/2010] [Accepted: 06/08/2010] [Indexed: 11/08/2022]
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Luyet C, Eichenberger U, Greif R, Vogt A, Szücs Farkas Z, Moriggl B. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth 2009; 102:534-9. [PMID: 19244265 DOI: 10.1093/bja/aep015] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND During paravertebral block, the anterolateral limit of the paravertebral space, which consists of the pleura, should preferably not be perforated. Also it is possible that, during the block, the constant superior costotransverse ligament can be missed in the loss-of-resistance technique. We therefore aimed to develop a new technique for an ultrasound-guided puncture of the paravertebral space. METHODS We performed 20 punctures and catheter placements in 10 human cadavers. A sonographic view showing the pleura and the superior costotransverse ligament was obtained with a slightly oblique scan using a curved array transducer. After inline approach, injection of 10 ml normal saline confirmed the correct position of the needle tip, distended the space, and enabled catheter insertion. The spread of contrast dye injected through the catheters was assessed by CT scans. RESULTS The superior costotransverse ligament and the paravertebral space were easy to identify. The needle tip reached the paravertebral space without problems under visualization. In contrast, the introduction of the catheter was difficult. The CT scan revealed a correct paravertebral spread of contrast in 11 cases. Out of the remaining, one catheter was found in the pleural space, in six cases there was an epidural, and in two cases there was a prevertebral spread of contrast dye. CONCLUSIONS We successfully developed a technique for an accurate ultrasound-guided puncture of the paravertebral space. We also showed that when a catheter is introduced through the needle with the tip lying in the paravertebral space, there is a high probability of catheter misplacement into the epidural, mediastinal, or pleural spaces.
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Affiliation(s)
- C Luyet
- Department of Anaesthesiology and Pain Therapy, Inselspital, University Hospital of Bern, and University of Bern, CH-3010 Bern, Switzerland
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Swann DG, Armstrong PJ, Douglas E, Brockway M, Bowler GM. The alkalinisation of bupivacaine for intercostal nerve blockade. Anaesthesia 1991; 46:174-6. [PMID: 2014890 DOI: 10.1111/j.1365-2044.1991.tb09402.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A double-blind randomised study was performed to investigate the effect of pH adjustment of bupivacaine, with adrenaline 1:200,000, on the duration of block and pain relief after intercostal nerve blockade following thoracotomy. One group (n = 10) received bupivacaine with adrenaline 1:200,000 (pH = 4.1) and the other (n = 10) received alkalinised bupivacaine with adrenaline 1:200,000 (pH = 6.9). There was no significant difference in block duration (mean 23.9 and 26.4 hours respectively) visual analogue pain scores or morphine usage. Patients were more likely to have a block during the first 12 hours if they received alkalinised bupivacaine (p less than 0.01, Chi-squared test). A progressive regression of block, not previously described, was observed, explicable by means of spread of local anaesthesia to adjacent intercostal nerves. Alkalinisation of bupivacaine with adrenaline for intercostal nerve blockade has little clinical benefit.
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Affiliation(s)
- D G Swann
- Department of Anaesthetics, Royal Infirmary Edinburgh
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