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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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Lee MG, Choi SU, Lim JK, Lee MJ, Hong JS, Baek MO, Yoon SZ, Park HY, Shin HJ. Ultrasound-guided sciatic nerve block at the midthigh level in a porcine model: A descriptive study. Vet Med Sci 2020; 6:543-549. [PMID: 32281259 PMCID: PMC7397899 DOI: 10.1002/vms3.265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/21/2020] [Accepted: 03/08/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There are a growing number of porcine models being used for orthopaedic experiments for human beings. Therefore, pain management of those research pigs using ultrasound (US)-guided nerve block can be usefully performed. The aim of this study is to determine optimal US approaches for accessing and localizing the sciatic nerve at the midthigh level, a relevant block site for hindlimb surgery in female Yorkshire pigs. METHODS As a first step, we dissected the intubated, blood-washed out pigs (n = 3) and confirmed the anatomical position of the sciatic nerve at midthigh level. After dissection, we found the sciatic nerve, connected with nerve stimulator, and checked the dorsiflexion or plantar flexion of the hindlimb. We matched the sciatic nerve location with the US image. After the pigs were euthanized, the neural structures of the sciatic nerve were confirmed by histological examination with H&E staining. In second step, a main US-guided sciatic nerve block study was done in the intubated, live pigs (n = 8) based on the above study. RESULTS In lateral position, the effective US-guided nerve block site was about 6 cm from the patella crease level; immediately proximal to the bifurcation of the sciatic nerve into the tibial nerve and common peroneal nerve. The distal femur was selected as the landmark. There were no vessels or other nerves surrounding the sciatic nerve. The needle-tip was positioned less than 1 cm lateral from the distal femur and about 2 cm deep to skin. 'Donut sign' in US images was confirmed in all 16 nerves. CONCLUSIONS Midthigh level sciatic nerve is located superficially, which enables nerve block to be easily performed using US. This is the first study to describe midthigh sciatic nerve block in the lateral position under US guidance in a porcine model from a clinical perspective.
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Affiliation(s)
- Mi Geum Lee
- Department of Anesthesiology and Pain medicine, Gachon University College of Medicine, Incheon, South Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jae Kwan Lim
- Korea Artificial Organ Center, Korea University College of Medicine, Seoul, South Korea
| | - Mee Ju Lee
- Department of Anesthesiology and Pain medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ji Su Hong
- Department of Anesthesiology and Pain medicine, Korea University College of Medicine, Seoul, South Korea
| | - Mi Ok Baek
- Korea Artificial Organ Center, Korea University College of Medicine, Seoul, South Korea
| | - Seung Zhoo Yoon
- Department of Anesthesiology and Pain medicine, Korea University College of Medicine, Seoul, South Korea
| | - Hee Yeon Park
- Department of Anesthesiology and Pain medicine, Gachon University College of Medicine, Incheon, South Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain medicine, Korea University College of Medicine, Seoul, South Korea
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Abstract
Even when performed by skilled operators, locating the nerves can be challenging in small exotic pets; in such cases, the use of an electrical nerve stimulator may be useful to confirm the correct identification of the target nerve. Exotic animal anesthesia and analgesia have dramatically progressed over the past decade and continue to do so as more research and technologies develop. Technological advancements such as airway devices, endoscopic intubation techniques, positive intermittent pressure ventilators, and invasive and noninvasive blood pressure monitors have played a significant role in improving patient safety and the anesthetic outcomes of exotic animals.
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Silva Herrera RE, Serrá Sandoval A, Gonzalez Venegas M, de Lara González S, Gracia J, Sala-Blanch X. Cross-sectional area of the median nerve after intraneural vs perineural low volume administration. ACTA ACUST UNITED AC 2018; 66:122-128. [PMID: 30528459 DOI: 10.1016/j.redar.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION To recognise the relationship between the needle tip and the median nerve during peripheral nerve block is of interest to avoid neural damage. However, signs of intraneural injection are not clearly established. The aim of this study was to define the changes observed in the peripheral nerve after the intraneural or perineural administration of 1ml of solution. MATERIAL AND METHODS Ultrasound guided median nerve blocks were performed in the forearm of 10 fresh cadavers on 60 occasions (3 per forearm). They were randomised into the intraneural (n=30) or perineural (n=30) location of the needle tip, after the consensus of location by 7 specialists. After 1ml of solution was injected an evaluation was made of the changes in the cross-sectional area of the nerve, as well as the displacement along the nerve. RESULTS The cross-sectional area of the median nerve was increased in both groups, however, the increase was significantly higher in the intraneural group (perineural 0.007±0.013cm2 vs. intraneural 0.032±0.021cm2, P<.0001). An increase of more than 27% of the area ensures an intraneural injection in the median nerve according to the ROC curve analysis. Both proximal and distal diffusion were observed more frequently in the intraneural group (proximal: 86% vs 14%, P<.0001, Distal: 43% vs 4%, P<.0001). CONCLUSIONS Based on this experimental study, it is concluded that the injection of a small volume (1ml) allows to discriminate the disposition of the intraneural vs perineural needle in a high percentage of cases. Therefore, it is suggested that this "dose test" should be considered in the safety algorithms if it is required to reduce the incidence of intraneural injection.
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Affiliation(s)
| | - A Serrá Sandoval
- Facultad de Medicina, Universitat de Barcelona, Barcelona, España
| | | | | | - J Gracia
- Hospital Clinic, Universitat de Barcelona, Barcelona, España
| | - X Sala-Blanch
- Facultad de Medicina, Universitat de Barcelona, Barcelona, España; Hospital Clinic, Universitat de Barcelona, Barcelona, España.
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Portela DA, Verdier N, Otero PE. Regional anesthetic techniques for the pelvic limb and abdominal wall in small animals: A review of the literature and technique description. Vet J 2018; 238:27-40. [PMID: 30103913 DOI: 10.1016/j.tvjl.2018.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 06/24/2018] [Accepted: 07/13/2018] [Indexed: 11/17/2022]
Abstract
Increasing interest in using peripheral nerve blocks in small animals is evident, given the numerous studies published recently on this topic in important veterinary journals. Initially, research was focused on intraoperative analgesia to the pelvic limb, and several descriptions of lumbosacral plexus, femoral and sciatic nerve blocks have been described in studies. There is recent interest in developing techniques for somatosensory blockade of the abdominal wall. This article is the second part of a two-part review of regional anesthesia (RA) in small animals, and its aim is to discuss the most relevant studies in the veterinary literature, where objective methods of nerve location have been used, and to illustrate in pictures the currently used techniques for providing RA to the abdominal wall and the pelvic limb in small animals.
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Affiliation(s)
- D A Portela
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA.
| | - N Verdier
- Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Buenos Aires, Argentina
| | - P E Otero
- Universidad de Buenos Aires, Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Buenos Aires, Argentina
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The concept of protective nerve stimulation for ultrasound guided nerve blocks. Med Hypotheses 2017; 107:72-73. [DOI: 10.1016/j.mehy.2017.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/14/2017] [Indexed: 11/18/2022]
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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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Krol A, De Andres J. Plexus and peripheral nerve block anaesthesia--a step beyond ultrasound or full circle? ACTA ACUST UNITED AC 2016; 63:129-34. [PMID: 26782289 DOI: 10.1016/j.redar.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022]
Affiliation(s)
- A Krol
- Department of Anaesthesia and Chronic Pain Service, St Georges University Hospitals, London, UK.
| | - J De Andres
- Department of Anaesthesia, Critical Care and Pain Management, University of Valencia, School of Medicine, General University Hospital, Valencia, Spain
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Helen L, O'Donnell BD, Moore E. Nerve localization techniques for peripheral nerve block and possible future directions. Acta Anaesthesiol Scand 2015; 59:962-74. [PMID: 25997933 DOI: 10.1111/aas.12544] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/24/2015] [Accepted: 04/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block. METHODS This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem. RESULTS To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques. CONCLUSIONS Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.
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Affiliation(s)
- L. Helen
- Sensing and Separation Group; Chemistry Department and Life Science Interface Group; Tyndall National Institute; University College Cork; Cork Ireland
| | - B. D. O'Donnell
- Department of Anesthesia; Cork University Hospital & ASSERT for Health Centre; University College Cork; Cork Ireland
| | - E. Moore
- Sensing and Separation Group; Chemistry Department and Life Science Interface Group; Tyndall National Institute; University College Cork; Cork Ireland
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DUGER C, ISBIR AC, KAYGUSUZ K, KOL IOZDEMIR, GURSOY S, OZTURK H, MIMAROĞLU C. The importance of needle echogenity in ultrasound guided axillary brachial plexus block: a randomized controlled clinical study. Int J Med Sci 2013; 10:1108-12. [PMID: 23869186 PMCID: PMC3714386 DOI: 10.7150/ijms.6598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/18/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE In this study we aimed to compare the echogenic needles and the nerve stimulation addition to non-echogenic needles in ultrasound guided axillary brachial plexus block for upper extremity surgery. METHODS 90 patients were enrolled to the study. The patients were allocated into three groups randomly: Group E (n=30): ultrasound guided axillary block using echogenic needle, Group N (n=30): ultrasound guided axillary block using non-echogenic needle, Group NS (n=30): ultrasound guided axillary block using non-echogenic needle with nerve stimulator assistance. Duration of block procedure, mean arterial pressure, heart rate, pulse-oximetry, onset time of sensory and motor block, duration of sensory and motor block, time to first analgesic use, total need for analgesics, postoperative pain scores, patient and surgeon satisfaction scores were recorded. RESULTS Duration of block procedure values were lower in group E and NS, sensory and motor block durations, were significantly lower in group N. Sensorial and motor block onset time values were found lower in group NS but higher in group N. Patient and surgeon satisfaction scores were found lower in group N. CONCLUSION We conclude that ultrasound guided axillary block may be performed successfully using both echogenic needles and nerve stimulation assisted non-echogenic needles.
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Affiliation(s)
- Cevdet DUGER
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Ahmet Cemil ISBIR
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Kenan KAYGUSUZ
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Iclal OZDEMIR KOL
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Sinan GURSOY
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Hayati OZTURK
- 2. Department of Orthopedics, Cumhuriyet University, School of Medicine, Sivas, TURKEY
| | - Caner MIMAROĞLU
- 1. Department of Anesthesiology, Cumhuriyet University, School of Medicine, Sivas, TURKEY
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Distale Blockaden des N. ischiadicus. Anaesthesist 2013; 62:183-88, 190-2. [DOI: 10.1007/s00101-013-2150-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 01/18/2013] [Accepted: 01/29/2013] [Indexed: 11/25/2022]
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