Safety of multiple, simultaneous continuous peripheral nerve block catheters in a patient receiving therapeutic low-molecular-weight heparin

Ultrasound-guided popliteal sciatic nerve block for surgical anesthesia in wound care patients with ongoing anticoagulant/antiaggregant therapy: A single-center, prospective study

Ultrasound-guided peripheral nerve blocks may be a good alternative in patients under antithrombotic drugs. We evaluated the efficacy of ultrasound-guided popliteal sciatic nerve block in patients undergoing lower extremity wound debridement of whom antithrombotic drugs could not be stopped. We focused on hemorrhagic complications related to sciatic nerve block. Wound care patients followed by Cardiovascular Surgery Department scheduled for lower extremity wound surgery were included in this prospective observational study. Data was collected between March 2021 and September 2022. All patient were under antithrombotic therapy and discontinuation of anticoagulant drugs were not possible. Single-insertion and multiple-injection sciatic nerve block at popliteal region was applied to all patients under ultrasound guidance. Primary outcome was the rate of hemorrhage. Secondary outcomes were block onset times, block success and postoperative analgesia times. Data of 105 patients was evaluated, 87 were male and 18 were female. Mean patient age was 61.92 ± 10.06, mean patient body mass index was 25.68 ± 6.33. All patients were under 1 or more antithrombotic drugs. Only one minor hematoma was detected by postoperative ultrasonography control in 1 patient. Hemorrhage complication rate was 1 of 105 (% 0.95, 95% CI, 0.00024-0.051). Overall block success rate was 99.05%. Mean block onset time was 16.27 ± 5.69 minutes. Mean postoperative analgesia time was 19.5 ± 11.22 hours. Sciatic nerve block under ultrasound guidance using in-plane technique was safe and provided sufficient surgical anesthesia and postoperative analgesia for lower extremity wound debridement surgery in patients on antithrombotic drugs.

Long-term analgesic effects of peripheral nerve block in patients with central post-stroke pain: A retrospective series

BACKGROUND

Central post-stroke pain (CPSP) has a detrimental effect on the quality of life of post-stroke patients. However, no definitive and effective method has been established yet for the treatment of CPSP.

OBJECTIVE

We aimed to examine the applicability of single-injection peripheral nerve blocks (PNBs) for the treatment of CPSP.

SUBJECTS

In this retrospective study, we included 22 patients (mean age = 56.3 years; 13 men and 9 women) diagnosed with CPSP who visited an outpatient rehabilitation clinic in Seoul National University Bundang Hospital between December 2018 and April 2020.

METHODS

The patients underwent ultrasound-guided single-injection PNB (lidocaine + epinephrine [1: 200,000]) according to the primary site of pain. The level of pain (measured using a numeric rating scale) was recorded before and after the PNB, and the occurrence of adverse events were also measured. The primary outcome of this study was the amount of pain reduction after PNB. Secondary outcome measures obtained 1 month after the PNB included the pain reduction rate 1 month after the PNB, the patient-reported satisfaction and effectiveness regarding the PNB, intention for re-injection, and the patients' willingness to recommend this procedure to others.

RESULTS

The mean pain reduction after PNB was 3.3 ± 2.8. PNB was associated with pain reduction that persisted for greater than 1 month in 68% (15/22) of the patients. Thirteen of 22 patients reported a pain reduction of 50% or more. The mean pain reduction rate was 43.6%. Of the 22 patients, 13 were willing to undergo a second round of treatment with PNB. Nine of them underwent the procedure. No adverse events were observed in this study.

CONCLUSIONS

Our study provides preliminary data suggesting that PNB could be an effective and feasible method to treat CPSP.

Regional anesthesia for the trauma patient: improving patient outcomes

Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.

Role of regional anesthesia in orthopedic trauma

Regional anesthesia plays a key role in the treatment of patients with orthopedic trauma. Trauma-induced pain can be in multiple locations, severe, and can predispose the patient to other morbidities. Additional complications as a result of the overdependence on opioids as a primary pain therapy that can be minimized or avoided with the use of regional anesthesia. Both neuraxial and peripheral regional techniques in patients with orthopedic trauma should be incorporated into the patient care plan and recognized as an essential therapeutic intervention in the overall treatment of this unique patient population.

Diffuse complex regional pain syndrome in an adolescent: a novel treatment approach

OBJECTIVES

Late diagnosis and management of complex regional pain syndrome (CRPS) can have severe consequences. We report the case of a young adolescent who failed several months of medical and physical therapy for CRPS, which was initially limited to one extremity but then spread to the remaining extremities.

METHODS

At the time of admission to our hospital, she had been unable to independently perform activities of daily living for several months. We placed an epidural catheter and 2 infraclavicular catheters under general anesthesia and ran continuous infusions of local anesthetic and morphine in the epidural catheter (ropivacaine 0.1% and preservative-free morphine [20 μg/mL] at 8 mL/h) and ropivacaine 0.1% 6 mL/h in each infraclavicular catheter.

RESULTS

Patients were started intense physical, occupational, and psychotherapeutic treatments the following day. Color and temperature of extremities normalized within 10 minutes from the time of the bolus of local anesthetic through the catheters. The patient was able to walk and use her hands 48 hours after the placement of the catheters. She was weaned off opioids during her hospital stay and was discharged home 9 days after her initial admission, and was able to walk and attend to her daily living activities.

DISCUSSION

The extensive use of regional anesthesia techniques can greatly benefit patients with CRPS during the acute phase of the rehabilitation process, which includes appropriate physical, and occupational therapy and psychological interventions. It is critical to continue physical therapy and psychological support after discharge from the hospital.

Regional anesthesia for acute traumatic injuries in the emergency room

Since the introduction of cocaine in 1884, regional nerve block procedures have been used in anesthesia practice for over 100 years. While almost all medical specialties use simple regional anesthesia techniques, anesthesia providers use a wider variety of more specific nerve block techniques than any other speciality. Anesthesiologists have assumed a vital role in recent military conflicts and, together with surgeons and emergency physicians, have introduced regional anesthesia techniques for the treatment and transport of injured soldiers. While such techniques have only been applied to a limited extent in civilian emergency settings, it is likely that current military experience will enhance future use of regional anesthesia techniques for the care of trauma patients in the civilian prehospital and emergency room settings.

Ultrasound guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter insertion

OBJECTIVE

Electrical stimulation (ES)- and ultrasound-guided placement techniques have been described for infraclavicular brachial plexus perineural catheters but to our knowledge have never been previously compared in a randomized fashion, leaving the optimal method undetermined. We tested the hypothesis that infraclavicular catheters placed via ultrasound guidance alone require less time for placement and produce equivalent results compared with catheters placed solely via ES.

METHODS

Preoperatively, patients receiving an infraclavicular perineural catheter for distal upper extremity surgery were randomly assigned to either ES with a stimulating catheter or ultrasound guidance with a nonstimulating catheter. The primary outcome was the catheter insertion duration (minutes) starting when the ultrasound transducer (ultrasound group) or catheter placement needle (stimulation group) first touched the patient and ending when the catheter placement needle was removed after catheter insertion.

RESULTS

Perineural catheters placed with ultrasound guidance took a median (10th-90th percentile) of 9.0 (6.0-13.2) minutes compared with 15.0 (4.9-30.0) minutes for stimulation (P < .01). All ultrasound-guided catheters were successfully placed according to the protocol (n = 20) versus 70% in the stimulation group (n = 20; P < .01). All ultrasound-guided catheters resulted in a successful surgical block, whereas 2 catheters placed by stimulation failed to result in surgical anesthesia. Six catheters (30%) placed via stimulation resulted in vascular punctures compared with none in the ultrasound group (P < .01). Procedure-related pain scores were similar between groups (P = .34).

CONCLUSIONS

Placement of infraclavicular perineural catheters takes less time, is more often successful, and results in fewer inadvertent vascular punctures when using ultrasound guidance compared with ES.