Local and Regional Anesthesia最新文献

Background: Successful brachial plexus blockade produces sympathetic blockade, resulting in increased skin temperature in the blocked segments. This study aimed to evaluate the accuracy of infrared thermography in predicting failed segmental supraclavicular brachial plexus block.

Methods: This prospective observational study included adult patients undergoing upper-limb surgery under supraclavicular brachial plexus block. Sensation was evaluated at the dermatomal distribution of the ulnar, median, and radial nerves. Block failure was defined as absence of complete sensory loss 30 min after block completion. Skin temperature was evaluated by infrared thermography at the dermatomal supply of the ulnar, median, and radial nerves at baseline, 5, 10, 15, and 20 min after block completion. The temperature change from the baseline measurement was calculated for each time point. Outcomes were the ability of temperature change at each site to predict failed block of the corresponding nerve using area under receiver-operating characteristic curve (AUC) analysis.

Results: Eighty patients were available for the final analysis. The AUC (95% confidence interval [CI]) for the ability of temperature change at 5 min to predict failed ulnar, median, and radial nerve block was 0.79 (0.68-0.87), 0.77 (0.67-0.86), and 0.79 (0.69-0.88). The AUC (95% CI) increased progressively and reached its maximum values at 15 min (ulnar nerve 0.98 [0.92-1.00], median nerve 0.97 [0.90-0.99], radial nerve 0.96 [0.89-0.99]) with negative predictive value of 100%.

Conclusion: Infrared thermography of different skin segments provides an accurate tool for predicting failed supraclavicular brachial plexus block. Increased skin temperature at each segment can exclude block failure in the corresponding nerve with 100% accuracy.

Background and aim: Ultrasound-guided continuous adductor canal block (cACB) is a conventional choice in patients undergoing total knee arthroplasty (TKA) for the management of the postoperative pain. This study aims to compare different catheter tip locations for cACB relative to the saphenous nerve (anteriorly vs posteriorly) in terms of efficacy and complications.

Methods: At the department of Surgical Sciences, Orthopedic Trauma and Emergencies of the University of Naples Federico II (Naples, Italy), between January 2020 and November 2021, retrospective comparative study was executed. Patients planned for TKA were included in the study if they met the follow inclusion criteria: patients undergone TKA; aged 50-85 years; body mass index (BMI) of 18-35 kg/m2; American Society of Anesthesiologists (ASA) physical status classification from I to III; subarachnoid technique for anesthesiology plane; continuous adductor canal block performed by an anesthetist with considerable experience. Patients were assigned to receive cACB with the catheter tip located anteriorly (Group 1, G1) or posteriorly to the saphenous nerve (Group 2, G2). Postoperative pain, ambulation ability, episodes of pump block and rate of catheter dislodgement and leakage were evaluated and analyzed.

Results: Altogether, 102 patients were admitted to the study (48 in G1 and 54 in G2). After the first 8 postoperative hours, in G1 17 patients (35.4%) had a VAS greater than 4, while in group 2 only 3 patients (5.6%) had a VAS greater than 4 (p-value <0.01). All patients of both groups showed ambulation ability in the postoperative period. No episode of leakage was recorded. While the catheter displacement rate was similar in the two groups (2.1% for G1 vs 3.7% for G2; p-value >0.05), the episodes of pump block were significantly less in G2 than in G1 (3.7% vs 20.8%; p-value <0.01).

Conclusion: In cACB for TKA, we found that positioning the catheter tip posteriorly to the saphenous nerve may lead to a greater postoperative analgesia and reduce the risk of pump block compared to placing the catheter tip anteriorly to the nerve.

Background: Interscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery.

Methods: We performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique.

Results: After statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters.

Conclusion: Interscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

Background and objectives: Studies demonstrate variations in the size and position of the nerves in the brachial plexus. The objective of this pilot study was to determine the effect of age, gender, BMI and side of body on the size and position of these nerves and to determine the feasibility of a further study.

Methods: Twenty healthy volunteers were recruited. The ultrasound position of the nerves was confirmed by a dynamic scan. The size of the nerves was calculated using the freehand calliper tool. A graph was designed to study the position of the nerves. ImageJ was used to analyse the position of the nerves. Student's t-tests were carried out to compare the gender and side of arm with the size of the nerve. Pearson's correlation coefficients were calculated to determine the correlation between BMI and age with the size of the nerves. The position of the nerves was compared between male and female, and left and right sides of the body.

Results: The mean size of the median nerve, musculocutaneous nerve, radial nerve and ulnar nerve was 0.099, 0.032, 0.179 and 0.076 cm2 (males) and 0.091, 0.022, 0.128 and 0.026 cm2 (females), respectively. There were significant differences between the size of nerves and gender in the musculocutaneous, radial and ulnar nerves (P <0.05). The correlations between the sizes of the nerves with BMI and age were not significant. The position of the radial nerves was found to be variable within the same genders and between males and females. The position of the nerves was variable between the left and right hand side.

Conclusion: The position and size of brachial plexus branches in axilla is very variable. This pilot study highlights the need for further research with larger sample sizes to fully understand the extent and implication of this variability.

Purpose: Chloroprocaine provides spinal anesthesia for day-case surgery lasting up to 40 minutes. Intravenous and spinal dexmedetomidine can prolong spinal anesthesia, but no data are available for the combination with chloroprocaine. This double-blind randomized controlled trial compares chloroprocaine with spinal or intravenous dexmedetomidine regarding block characteristics, micturition, and discharge times.

Patients and methods: After ethical approval and informed consent, 135 patients scheduled for knee arthroscopy were randomized to receive either 40mg spinal chloroprocaine (Chloro-group), 40mg chloroprocaine with 5 mcg spinal dexmedetomidine (Spinal Dex-group) or 40mg chloroprocaine with 0.5 mcg/kg IV dexmedetomidine (IV DEXgroup). Block characteristics, hemodynamic variables and the use of analgesics were registered. Voiding and discharge times were noted. A scoring system was used for micturition problems and sedation. Transient neurological symptoms (TNS) and other late side effects were evaluated after one week.

Results: Demographic data were similar between groups. Block onset times and intensity of motor block were comparable between groups. The time to L2 and Bromage 1 regression was prolonged in the SpinalDEx-group by approximately 30 minutes compared to the other groups (p < 0.01). First voiding as well as discharge from the hospital was prolonged in the Spinal Dex-group by approximately 40 minutes p < 0.01. There was no significant difference between groups regarding treatment of hypotension, sedation, micturition problems or the use of postoperative analgesics (P > 0.8). One patient experienced TNS.

Conclusion: Intrathecal but not intravenous (0.5 mcg/kg) dexmedetomidine can prolong chloroprocaine (40mg) spinal anesthesia when surgery is expected to last over 40 minutes. Despite a similar incidence of adverse effects, this also led to a postponed hospital discharge time.

Purpose: Transverse thoracic block is a new perioperative analgesic method for post-sternotomy discomfort. This study discusses the efficacy of an ultrasound-guided transversus thoracic muscle plane block (TTPB) in patients undergoing heart surgery, including sternotomy.

Patients and methods: In this prospective trial, 60 patients were randomly assigned to two groups: transversus (T) or general anesthesia (GA). Patients in the T group received TTPB with GA and 15 mL of 0.25% bupivacaine was administered on either side. Patients in the GA group received TTPB along with GA, but 15 mL saline was injected on either side instead. The patients were followed up postoperatively. The percentage of patients receiving additional opioids, extubation time, intensive care unit (ICU) length, postoperative morphine dose, and adverse events were documented.

Results: The percentage of patients requiring additional morphine was significantly lower in the T group (p<0.015). Pain scores were comparable between the groups at extubation time and 18 h postoperatively. At 8, 12, and 24 h after surgery, pain scores in the T group were significantly lower (P<0.001). The total amount of morphine required after surgery was much lower in the T group (8±0.74 mg), and the duration to initial analgesic necessity was significantly greater in the GA group (P<0.001). Patients in the GA group had a considerably longer ventilation time (11.07±0.64) (P<0.001). The ICU stay in the T group was substantially shorter (P<0.001), and postoperative complications were comparable.

Conclusion: For patients undergoing heart surgery, TTPB offers sufficient postoperative pain control, resulting in lower pain scores, lower postoperative analgesic doses, shorter extubation times, and shorter ICU stay lengths.

Introduction: For surgical procedures involving the hip and femur, various regional anesthetic techniques may be used to provide analgesia. Although there has been an increase in the use of lumbar plexus block (LPB), the technique may be time consuming and associated with complications. Suprainguinal fascia iliaca compartment block (FICB) is a potentially easier and safer alternative. The current study prospectively compares LPB with suprainguinal FICB.

Methods: This prospective, double-blinded, randomized, study included patients undergoing elective orthopedic procedures of the hip and/or femur. All study patients received general anesthesia with randomization to either an LPB or suprainguinal FICB using 0.5% ropivacaine with epinephrine and dexamethasone. Postoperative pain control was achieved with intravenous hydromorphone delivered by patient-controlled analgesia with scheduled acetaminophen and ketorolac. Outcome data included time to perform the block, perioperative opioid consumption, postoperative pain scores (VAS) and hospital length of stay.

Results: The study cohort included 15 patients between the ages of 7 and 16 years (LPB N = 7, FICB N = 8). The median block time was 6 minutes (IQR: 4.11) for the LPB group and 3 minutes (IQR: 3.6) for the FICB group (p = 0.107). Median postoperative pain scores were 4 (IQR: 0.6) for the LPB group and 2 (IQR: 0.5) for the FICB group (p = 0.032). There were no differences in the intraoperative or postoperative opioid and NSAID use between the two groups.

Discussion: The suprainguinal FICB provides analgesia that is at least as effective as a LPB following hip and femur surgery. Time to perform the block was shorter with the FICB due to the supine patient position and limited needle trajectory. Although we noted no adverse effects, the superficial needle trajectory of the FICB offers a less invasive approach and the potential for decreased risks of adverse effects.

Purpose: Sensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).

Materials and methods: Preparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.

Results: Anastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).

Conclusion: This anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.

Purpose: Treatment of chronic pain associated with occipital neuralgia (ON) is complex, and no consensus statement or guidelines have been published for ON management. This pilot study evaluated the efficacy and safety of cryoneurolysis for management of ON-associated chronic pain.

Patients and methods: The study was a prospective, multicenter, nonrandomized cohort study assessing the degree and duration of clinical effect of cryoneurolysis therapy for reducing pain in patients diagnosed with unilateral or bilateral ON. The primary outcome measure was improvement in pain due to ON from baseline to day 7, measured on an 11-point numeric rating scale for pain. Secondary outcome measures included duration of treatment effects and safety events, including anticipated observations and adverse events. Treatment effect was assessed at days 7, 30, and 56 by asking the patient if they were continuing to experience a treatment effect, with potential responses of "effect," "no effect," or "no longer effective." A posttreatment questionnaire evaluated patient satisfaction.

Results: Twenty-six patients (9 men, 17 women) with a mean age of 49.1 years enrolled and completed the study. A total of 64% (16/25) of participants reported a clinically important improvement of ≥2 points in numeric rating scale pain scores at day 7; similar results persisted to day 30. Treatment effects were reported by 50% (13/26) of participants at day 30, with a continued effect reported by 35% (9/26) of participants at day 56. Overall, ~70% of participants were satisfied with treatment at 7, 30, and 56 days. No serious anticipated observations, adverse events, or unanticipated adverse device effects were reported.

Conclusion: Cryoneurolysis provided significant relief from pain associated with ON ≤30 days after treatment and had an acceptable safety profile.