Local and Regional Anesthesia最新文献

The frail, elderly population is at a high risk of postoperative complications. Besides perioperative rehabilitation techniques and management by geriatric teams, the least invasive techniques in anesthesia are required, making regional anesthesia very interesting in terms of benefit-risk ratio. Among them, local anesthesia is a simple, reproducible, inexpensive technique applied to many superficial or deep surgeries, which should make it a gold standard for the frail person. This review provides an update on the current possibilities for various surgeries and exclusion.

Purpose: Ultrasound guidance during nerve blockade poses the challenge of maintaining in-plane alignment of the needle tip. The needle guidance device maintains needle alignment and assists with in-plane needle visualization. The purpose of this study is to evaluate the utility of this device by comparing procedure performance during brachial plexus blockade with the conventional approach.

Methods: After the Institutional Review Board approval and obtaining informed consent, 70 patients receiving either interscalene or supraclavicular nerve blocks were randomly assigned into 2 groups, a conventional approach versus utilizing the needle guidance device. An independent observer recorded: total procedure time; needle insertion time; number of unplanned redirections; and number of reinsertions. Additionally, physician satisfaction and ease of needle visualization were assessed.

Results: Data from seventy patients were analyzed. The median [25th percentile-75th percentile] time to complete the block by the device assisted needle guidance group was 3 (2-3.75) minutes and 4 (3-6) minutes in the conventional approach group (p < 0.001). Additionally, subgroup analyses were performed in the supraclavicular block and interscalene block. Supraclavicular blockade, needle insertion time (median [25th percentile-75th percentile] in seconds) (106 [92-162] vs 197 [140-278]), total procedure time (3 [2-3] vs 4.5 [4-6] in minutes) and unplanned needle redirections (2 [1-5] vs 5.5 [3-9]) were significantly lower in needle guidance group (p < 0.001). With interscalene blockade, needle insertion time (86 [76-146] vs 126 [94-295]) and unplanned needle redirections (2 [1-3] vs 4 [2-8.5]) were significantly lower with needle guidance (p < 0.001), but total procedure time was similar. All the physicians reported that they would use the needle guidance again, and 90% would prefer it for in-plane blocks.

Conclusion: Performing regional blocks using the needle guidance device reduces needle insertion time and unplanned needle redirections in brachial plexus blockade. Moreover, physician satisfaction also improved compared to the use of the conventional technique.

In today's applicant landscape, the SARS-COV-2 pandemic has drastically altered the traditional model of in-person interviews shifting it to an online format often conducted by web-based applications. Fellowship programs and naturally fellowship program directors face a new challenge of standardizing information to be distributed to prospective fellowship applicants through American Society of Regional Anesthesia and Pain Medicine (ASRA) common application. Here we describe a set of 11 criteria recommended by other similar studies selected for evaluation of online program training platforms, where only 13.3% of the acute and regional pain fellowship program online platforms met 75% of the criteria with limited presence in areas of research, rotation schedules, list of fellows, alumni, and life in the area. Additional considerations pertaining to the types of procedures performed, evaluation, mentorship, academic involvement, and teaching should be undertaken by the programs.

Purpose: Transmuscular quadratus lumborum (TQL) block has been described as an effective option for postoperative analgesia in patients undergoing hip replacement with single injection described as providing analgesia for up to 24 h. We hypothesize that a TQL block, when compared to fascia iliaca block (FIB), will provide better analgesia and less motor block in the initial 24-h postoperative period.

Patients and methods: Fifty patients undergoing elective hip replacement surgery, ASA I-III, were included in the study. Patients were randomized into two groups. Patients in group A received spinal anesthesia followed by FIB. Patients in group B received spinal anesthesia followed by TQLB. Postoperative pain scores and motor block were assessed at 6 and 24 hours. The primary outcome measure was 24 h total morphine consumption. Secondary outcome measures included pain score (VNS) and motor block (modified Bromage scale) at 6 and 24 h postoperatively.

Results: There was no statistical difference in morphine consumption between the two groups (p-value 0.699). There was no difference in pain scores at 6 h (p-value 0.540) or 24 h (p-value 0.383). There was no difference in motor block at 6 h (p-value 0.497) or at 24 h (p-value 0.773).

Conclusion: Transmuscular quadratus lumborum block along with spinal anesthesia for patients undergoing elective hip replacement surgery does not reduce opioid consumption or motor weakness when compared to fascia iliaca block. The results and conclusion apply to a dose of 20 mL of 0.25% bupivacaine used in each group.

Purpose: We tested the hypothesis that the addition of a single-injection proximal sciatic nerve block to an adductor canal block would significantly reduce pain scores and opioid requirements compared to a group of patients that received only an adductor canal or femoral nerve block for medial patellofemoral ligament reconstruction in pediatric patients. The primary end-point is the number of patients achieving a Patient Acceptable Symptom State (PASS) (pain score less than four) for the entire 24-hour postoperative period in patients with and without a proximal sciatic block.

Patients and methods: This is a retrospective cohort study of 144 consecutive pediatric patients, ages 10 to 18 years, undergoing medial patellofemoral ligament reconstruction with peripheral nerve blockade for postoperative analgesia from 2016-2020 at a pediatric orthopedics children's hospital. Patients were divided into 2 cohorts with and without a proximal sciatic nerve block: group A/F: adductor canal or femoral CPNB and group AS: adductor canal CPNB and a proximal single-injection sciatic nerve block.

Results: There was strong evidence for an increase in the number of patients who reported a pain score less than four for the entire 24-hour postoperative period in the group that received the additional proximal sciatic block. (PASS: A/F 13/62 (21%) vs AS 43/82 (52%), p<0.001) There was strong evidence for a reduction in mean and maximum pain scores and opioid requirements in the first 24-hours after surgery in the proximal sciatic group.

Conclusion: The addition of a proximal sciatic nerve block was associated with significantly reduced mean and maximum pain scores and opioid requirements after medial patellofemoral ligament reconstruction in pediatric patients and supports a randomized clinical trial to confirm these findings. Based on the results of this study we recommend the addition of a proximal sciatic nerve block, anterior or posterior, to an adductor canal block to provide improved analgesia and reduced opioid requirements in the 24-hours after MPFLR in pediatric patients.

Introduction and objectives: Local anesthesia is essential in dentistry in providing intraoperative analgesia and anesthesia. However, knowledge related to its use for management of post-operative pain is limited. Perioperative pain management is especially important for root canal treatment (ie, endodontic therapy), performed by endodontists. In this study, we sought to better understand endodontists' attitudes regarding the use of long-lasting anesthetic, namely 0.5% bupivacaine HCl with 1:200,000 epinephrine, for the management of post-endodontic pain. Additionally, we aimed to understand the perspectives of dental patients about receiving longer lasting anesthesia for endodontic therapy and to determine factors that affect their anesthetic preferences within the orofacial region.

Methods: An email invitation to participate in an anonymous online survey was sent to members of the American Association of Endodontists. Also, 82 patients attending an in-person visit to an endodontic clinic were recruited to the study.

Results: Data from 474 endodontic practitioners and 82 patients included in analysis. Among practitioners, the majority reported to either never (33.31%) or rarely (34.84%) using bupivacaine. Most chose "I don't think I need it" (47%) and "patient discomfort because of longer duration of soft tissue anesthesia" (30.81%) as reasons for not preferring the use of bupivacaine. Of the practitioners who reported at least rare use, most chose bupivacaine for post-operative pain management (78.02%). Conversely, 52% of patients reported that they were likely/most likely to request long-lasting anesthetics for post-operative pain control.

Conclusion: Bupivacaine is rarely used as a post-operative pain management strategy for endodontic therapy. Specifically, bupivacaine is not preferred not because of adverse events, toxicity, or slow onset concerns, but rather, because of longer duration of soft tissue anesthesia. However, our data suggest that patients may be willing to receive long-lasting anesthesia. Further patient-centered research should investigate the use of long-lasting anesthetic agents for management of post-endodontic pain.

Background: Hepatic resection is a major abdominal surgery with challenging pain management. We aimed to investigate the effect of erector spinae plane block (ESPB) with opioid free anesthesia (OFA) in cirrhotic patients scheduled for liver resection on perioperative pain management in terms of hemodynamic stability. Secondarily, we assessed time to first request for analgesia and perioperative fentanyl consumption, nausea and vomiting within 24 hours after surgery.

Methods: Forty patients were randomized to block group (n = 20): OFA with ESPB and conventional group (n = 20): conventional balanced anesthesia with opioids (OFA associated non-opioid drugs [dexmedetomidine, magnesium sulfate, xylocaine, and acetaminophen] and ESPB). Bilateral ESP block was done with ultrasound guidance at the level of thoracic vertebrae T 6-7, the local anesthetic dose was 20 mL Bupivacaine 0.25% with adjuvant dexmedetomidine (0.5 µg/kg) on each side. We monitored hemodynamic stability as the primary endpoint (heart rate, mean arterial blood pressure, and cardiac output).

Results: Bilateral ESPB offered somatic and visceral analgesia for hepatic resection patients with no intraoperative fentanyl required. Postoperatively, the block group with dexmedetomidine adjuvant to the local anesthesia drugs showed delay in the first request for analgesia (p = 0.092) and decreased fentanyl requirement (p < 0.001), so no patient in the ESP group suffered from postoperative nausea and vomiting compared to 50% in the conventional group (p < 0.001).

Conclusion: Bilateral ESP block with OFA is an effective approach for intra- and postoperative analgesia in cirrhotic patients undergoing liver resection.

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.