Regional anesthesia最新文献

Background and objectives: Genitofemoral nerve (GFN) block is a known side effect of a lumbar sympathetic block (LSB), although the incidence has not been well documented. Furthermore, genitofemoral neuralgia can occur following neurolytic LSB. Because the level at which the GFN exits the psoas sheath varies, this study was designed to identify differences in the incidence of GFN block following LSB at the level of the second versus the fourth lumbar vertebrae.

Methods: Patients requiring LSB to evaluate chronic lower extremity pain were prospectively studied. Patients were injected at the second lumbar (L2 group) or fourth lumbar (L4 group) vertebral body depending on the location of the pain syndrome in the lower extremity. Lumbar sympathetic blocks were performed using 10 mL of a 0.5% bupivacaine solution with radiocontrast; spread of injectate was verified using fluoroscopy. An observer evaluating for presence of GFN block was blinded to the lumbar level of injection.

Results: Thirty patients were enrolled (L2 group, n = 15; L4 group, n = 15). Spread of local anesthetic/radiocontrast solution was limited to approximately one vertebral body above and one below the target level. There was no difference in the ability to achieve a LSB; success rates were 66% and 73% using L2 and L4, respectively. The incidence of GFN block was 0% (0/15) in the L2 group versus 40% (6/15) in the L4 group; this was statistically significant (P = .017, Fisher's exact test).

Conclusions: The GFN is less likely to be blocked when the LSB is performed near the second lumbar vertebra as compared with the fourth lumbar vertebra.

Background and objectives: Postoperative analgesia and antiemetic efficacy after intrathecal neostigmine were investigated in a randomized, double-blind, placebo-controlled trial of 100 patients undergoing abdominal hysterectomy.

Methods: The patients were assigned to one of five groups (n = 20), and received intravenous prior to the spinal block the antiemetic test drug (except propofol) and 0.05 mg/kg midazolam. The control group (group C), the neostigmine group (group N), and the propofol group (group P) received saline as the test drug. The droperidol group (group D) received 0.5 mg intravenous droperidol, and the metoclopramide group (group M) 10 mg intravenous metoclopramide. Group P was single-blinded and had an intravenous continuous propofol infusion (2-4 mg/kg/h) turned on 10 minutes after the spinal injection. The intrathecal drugs administered were 20 mg hyperbaric bupivacaine (0.5%) associated with either 100 microg neostigmine or saline (for group C). Nausea, emetic episodes, and the need for rescue medication were recorded for the first 24 hours postoperative and scored by the Visual Analog Scale (VAS).

Results: Time-to-first-rescue medication and rescue medications in 24 hours were similar among the groups (P = .2917 and P = .8780, respectively). Intrathecal 100 microg neostigmine was associated with a high incidence of nausea and vomiting perioperative, leading to a high consumption of antiemetics (P < .002). None of the antiemetic test drugs were effective in preventing nausea and vomiting after 100 microg neostigmine.

Conclusions: Intrathecal neostigmine (100 microg) was ineffective for postoperative analgesia after abdominal hysterectomy due to side effects of nausea and vomiting.

Background and objectives: Herpes zoster infection in elderly patients frequently results in disabling pain, carries a high risk of postherpetic neuralgia (PHN), and can pose a significant therapeutic challenge.

Methods: We describe a successful use of the perivascular technique of lumbar plexus blockade ("three-in-one block") for treatment of pain during acute herpes zoster infection in an 82-year-old severely ill patient in whom other modalities were contraindicated.

Results: Three-in-one block using 40 mL of 0.25% bupivacaine with 1:300,000 epinephrine resulted in excellent pain relief that lasted for 2 weeks.

Conclusions: The perivascular technique of lumbar plexus blockade may be a useful alternative to epidural and paravertebral techniques of lumbar blockade in the occasional patient for whom these other approaches are contraindicated.

Background and objectives: Postdural puncture headache can recur following an epidural blood patch but usually does so within the first week. However, a late recurrence was encountered in a 31-year-old woman with probable lupus vasculitis.

Methods: The patient underwent a diagnostic lumbar puncture and suffered a postdural puncture headache. She was treated with an epidural blood patch and had complete resolution of her headache. Five weeks later, she suffered a sudden recurrence of an identical headache and underwent a repeat epidural blood patch.

Results: The second headache, like the first, was immediately and completely resolved.

Conclusions: A review of risk factors for postdural puncture headache and the role of an epidural blood patch suggests a possible explanation for the late recurrence in this case.

Background and objectives: Interpleural anesthesia blocks pain perception from the thoracoabdominal wall without impairment of leg function. Bilateral interpleural anesthesia is not recommended because of possible bilateral impairment of respiratory function. Infiltration of the retromediastinum with local anesthetic might cause bilateral thoracoabdominal somatic block and block of sympathetic afferents from the abdominal cavity without impairing respiration.

Method: Distribution of stained fluid was studied after injection into the retromediastinum through a catheter placed about 10 cm cephalad to the diaphragm via the esophageal hiatus in three human cadavers of normal size and in six anesthetized pigs of 20-30 kg. In the pigs serum levels of bupivacaine were measured after injection of 10 mL of 0.5% bupivacaine stained with 1 mL of methylene blue.

Results: The injected Dye stained intercostal nerves 6-11 in cadavers and 5-12 in pigs symmetrically on both sides, along with the adjacent parts of the sympathetic chain and both vagal nerves but not the phrenic nerves. During the sampling period of 50-60 minutes, bupivacaine serum concentrations rose slowly to a maximum of 4.2 micrograms/mL.

Conclusions: Block of pain perception from the abdominal wall and cavity is possible by injection of local anesthetic into the retromediastinum via a catheter introduced through the esophageal diaphragm hiatus. The block would not be expected to impair respiratory or leg function. Its efficacy and safety have yet to be established.