Regional Anesthesia and Pain Medicine最新文献

Introduction: Superficial parasternal intercostal plane blocks have grown in clinical use for cardiac surgery as a targeted fascial plane block for median sternotomy. Despite this, there remains no consensus on technique for optimal parasternal spread of injectate. The primary objective of this cadaveric study was to evaluate parasternal spread of injectate of single versus two-level superficial parasternal intercostal plane injections with the needle tip positioned on the anterior surface of the costal cartilage.

Methods: We performed 10 single-level injections at T4 and 10 two-level injections at T3 and T5 on alternating sides in 10 fresh frozen cadavers. All injections were ultrasound guided with a parasagittal ultrasound probe orientation and an in-plane needle orientation. Anatomic dissections were performed immediately following injections.

Results: Parasternal spread of injectate was greater with two-level injections at T3 and T5 costal cartilages than with single-level injections at the T4 costal cartilage, with two-level injections consistently spreading to the T2-T5 intercostal spaces. Median (Q1, Q3) intercostal space spread for single-level injections was 2.0 (2.0-2.5). Median (Q1, Q3) intercostal space spread for two-level injections was 4.0 (4.0-4.375).

Conclusions: Two-level injections with the needle tip located on the anterior surface of the costal cartilage resulted in improved parasternal spread compared with single-level injections.

Introduction: This observational study evaluates diaphragmatic excursion and thickening fraction before and after proximal analgesic brachial plexus block in 99 patients undergoing shoulder surgery.

Methods: This study has a prospective, observational, blinded design and evaluates three methods of sonographic assessment: (1) the excursion of the dome of the diaphragm, (2) the thickening fraction of the zone of apposition, and (3) the excursion of the zone of apposition. All three methods of assessment were used prior to and within 30 min of a proximal brachial plexus block for shoulder surgery. The blocks were all ultrasound-guided and were either an interscalene block or a superior trunk block with 15-20 mL of ropivacaine 0.5% or bupivacaine 0.25% with 1:400 000 epinephrine. The type of block was not randomized and was left to the discretion of the anesthesiologist performing the nerve block.

Results: Assessment of the excursion of the zone of apposition and the thickening fraction was possible bilaterally in all patients. Assessment of the excursion of the dome of the diaphragm was consistently possible on the right side but only possible in about half of the patients (48.8% preblock and 46.3% postblock) on the left hemithorax. The median decrease in diaphragmatic function was between 42% and 82% dependent upon the type of nerve block, patient sex, and method of evaluation. One patient developed complete plegia, and three-quarters of all patients developed >50% weakness. Female sex and interscalene block were associated with greater weakness.

Conclusion: The data suggest that the assessment of the excursion of the zone of apposition on the lateral aspect of the chest using a linear probe is consistently successful in measuring both baseline and postblock values of diaphragmatic excursion, and thus it may be a helpful tool in the perioperative period. Future studies are needed to establish use in other clinical settings as well as assessment of learning curves and reliability of this emerging technique.

Background and objectives: Popliteal plexus block (PPB) has shown moderate improvements in multimodal analgesia following total knee arthroplasty (TKA) while preserving motor function. However, the optimal analgesic volume for PPB remains unknown, and concerns exist regarding potential volume-dependent motor nerve involvement. This study investigates whether increasing the volume of local anesthetic for PPB affects muscle function and motor nerve involvement.

Methods: In this randomized, controlled, blinded trial, 40 healthy volunteers received one active nerve block and one sham block in each leg. Participants were randomized into three PPB groups receiving 10 mL, 20 mL, or 30 mL of 1% lidocaine, with 20 observations per group. Additionally, 10 femoral nerve blocks and 10 sciatic nerve blocks were included as reference groups to confirm motor nerve involvement. The primary outcome was relative changes in maximum voluntary isometric contraction (MVIC) of ankle plantar- and dorsiflexion. Secondary outcomes included relative changes in MVIC of knee extension, relative changes in compound muscle action potential of the gastrocnemius, anterior tibial, vastus medialis, and vastus lateralis muscles and frequency of saphenous nerve involvement.

Results: There were no significant differences in motor function between the three PPB groups for any MVIC measures (p≥0.1). Compound muscle action potential changes did not indicate clinically relevant motor nerve involvement across PPB groups. Saphenous nerve involvement was inconsistent, affecting 40% (10 mL), 40% (20 mL), and 60% (30 mL) of cases (p=0.3), suggesting ineffective sensory block of the femoral nerve's medial knee contributions.

Conclusion: Increasing the volume of local anesthetic for PPB does not impair muscle function or significantly involve motor nerves, supporting its motor-sparing efficacy. PPB inconsistently affects the femoral nerve's sensory contributions to the knee, emphasizing its role as an adjunct to femoral triangle or adductor canal blocks in clinical practice. Concerns of muscle impairment should not hinder future clinical trials from exploration of the optimal analgesic volume for PPB.

Trial registration number: NCT05464862.

Pediatric regional anesthesia offers significant benefits, yet its adoption faces barriers, including perceived overcomplexity. This study aimed to identify and establish a set of core, high-value, low-complexity nerve blocks to improve perioperative pain management in pediatric patients. A four-round modified Delphi consensus study was conducted with an international panel of pediatric and regional anesthesia experts. An initial long list of regional techniques was compiled by the Steering Committee and refined through iterative input. Panelists rated each technique on a 10-point Likert scale for importance. Consensus was defined as ≥75% of panelists assigning a mean importance score of ≥8. Techniques receiving 50%-74% agreement were categorized as having strong agreement and considered for inclusion. The final selection was confirmed through a virtual roundtable discussion. Thirty-three experts representing 12 pediatric and regional societies participated. Consensus was reached on six regional techniques, with strong agreement (*) on two additional techniques, identifying eight core pediatric regional anesthesia blocks: supraclavicular brachial plexus block, rectus sheath block, transverse abdominis plane block*, suprainguinal fascia iliaca block*, femoral nerve block, adductor canal block, popliteal sciatic nerve block, and landmark-based caudal block. This consensus-driven framework defines a core set of pediatric regional anesthesia techniques that balance clinical effectiveness, feasibility, and accessibility. These findings provide a practical entry point for practitioners looking to incorporate pediatric regional anesthesia into their practice, regardless of prior experience. Future efforts should focus on standardized training, implementation research, and policy initiatives to support widespread adoption and improve perioperative pain management in children globally.

Background: To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

Methods: Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

Results: After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

Conclusions: The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Background: Cesarean section (CS) rates have increased globally, necessitating effective anesthesia management. Single-shot spinal anesthesia has limitations due to its duration and the dose-limiting adverse effects of local anesthetics.

Objectives: To evaluate the effectiveness and safety of intrathecal adjuvants combined with local anesthetics in the perioperative management of CS pain.

Design: Systematic review with network meta-analysis.

Data sources: PubMed, Cochrane Library for Clinical Trials, and Embase.

Eligibility criteria: We included women undergoing CS under single-shot spinal anesthesia with any intrathecal drug or placebo added to a long-acting local anesthetic. We selected single- or double-blind, parallel-group, randomized controlled trials (RCTs) reported in English. We excluded crossover, non-randomized, up-and-down dose-finding studies and clinical trials comparing the same drugs in all study arms.

Results: We included 166 RCTs with 14 925 patients assigned to 32 interventions. Buprenorphine and diamorphine were the highest-ranked treatments for reducing pain intensity at 24 hours, though not statistically significant. Morphine alone or in combination with meperidine, neostigmine, epinephrine, or nalbuphine significantly increased the duration of effective analgesia and reduced opioid consumption. Dexmedetomidine and morphine significantly prolonged the motor block duration. The safety profile of intrathecal adjuvants was generally adequate.

Conclusions: While the strength of evidence, overall, was very low to low, our study suggests that while none of the interventions significantly reduced pain intensity at 24 hours, several significantly prolonged effective analgesia and reduced postoperative opioid consumption. Dexmedetomidine and morphine prolonged the duration of motor block. None of the intrathecal adjuvants evaluated significantly increased the occurrence of severe adverse events. Future large-scale RCTs are essential to provide more robust evidence.

Prospero registration number: CRD42024479424.

Background: There are conflicting data on the efficacy of transnasal topical anesthetic approaches intended to achieve a pterygopalatine ganglion block, specifically regarding the extent to which local anesthetics reach the pterygopalatine fossa. This cadaveric study aims to determine whether bupivacaine can reach the pterygopalatine fossa following topical administration near the sphenopalatine foramen using endoscopically assisted cotton ball placement.

Methods: Nine fresh cadavers underwent topical nasal administration of a solution containing bupivacaine, methylene blue, and iodine contrast. Under direct endoscopic visualization, an absorbent cotton ball was positioned intranasally adjacent to the sphenopalatine foramen. CT was used to confirm correct placement and measured relevant anatomical distances. Tissue biopsies from the pterygopalatine fossa were collected via a transmaxillary surgical approach and analyzed using high-performance liquid chromatography-mass spectrometry.

Results: Bupivacaine was detected in all pterygopalatine fossa biopsy samples except one, which was the farthest (17.5 mm) from the sphenopalatine foramen. Concentrations exceeded 1.00 µg/g in 29% and 0.10 µg/g in 71% of samples. The concentration decreased exponentially with distance from the application site, following a one-phase decay model (R²=0.74).

Conclusions: These findings demonstrate that bupivacaine can reach the pterygopalatine fossa from the nasal cavity when topically applied near the sphenopalatine foramen under endoscopic assistance, supporting the feasibility of such an approach. They also suggest the main mean of transport is simple diffusion, meaning that optimizing bupivacaine concentration, duration of application, and precise placement of the absorbent cotton ball are crucial for maximizing the block's clinical efficacy.