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Rhyner P, Cachemaille M, Goetti P, Rossel JB, Boand M, Farron A, Albrecht E. Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia: a randomized controlled unblinded trial. Reg Anesth Pain Med 2024; 49:313-319. [PMID: 37541683 DOI: 10.1136/rapm-2023-104681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION Previous trials favored a continuous interscalene brachial plexus block over a single injection for major shoulder surgery. However, these trials did not administer a multimodal analgesic regimen. This randomized, controlled unblinded trial tested the hypothesis that a continuous infusion of local anesthetic for an interscalene brachial plexus block still provides superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. METHODS Sixty patients undergoing shoulder arthroplasty or arthroscopic rotator cuff repair were randomized to receive a bolus of ropivacaine 0.5%, 20 mL, with or without a continuous infusion of ropivacaine 0.2% 4-8 mL/hour, for an interscalene brachial plexus block. Patients were provided with intravenous morphine patient-controlled analgesia. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary outcomes included pain scores at rest and on movement, and functional outcomes, measured over 48 hours after surgery. RESULTS Median (IQR) cumulative intravenous morphine consumption at 24 hours postoperatively was 10 mg (4-24) in the continuous infusion group and 14 mg (8-26) in the single injection group (p=0.74). No significant between-group differences were found for any of the secondary outcomes. CONCLUSIONS A continuous infusion of local anesthetic for an interscalene brachial plexus block does not provide superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. The findings of this study are limited by performance and detection biases. TRIAL REGISTRATION NUMBER NCT04394130.
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MESH Headings
- Humans
- Male
- Female
- Brachial Plexus Block/methods
- Middle Aged
- Anesthetics, Local/administration & dosage
- Aged
- Pain, Postoperative/prevention & control
- Pain, Postoperative/diagnosis
- Infusions, Intravenous
- Ropivacaine/administration & dosage
- Analgesia, Patient-Controlled/methods
- Morphine/administration & dosage
- Ketorolac/administration & dosage
- Dexamethasone/administration & dosage
- Pain Measurement
- Arthroscopy/adverse effects
- Analgesics, Opioid/administration & dosage
- Amides/administration & dosage
- Treatment Outcome
- Drug Therapy, Combination
- Arthroplasty, Replacement, Shoulder/methods
- Arthroplasty, Replacement, Shoulder/adverse effects
- Acetaminophen/administration & dosage
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Affiliation(s)
- Patrick Rhyner
- Department of Anesthesia, CHUV, Lausanne, Vaud, Switzerland
| | | | - Patrick Goetti
- Department of Orthopedic Surgery, CHUV, Lausanne, Vaud, Switzerland
| | - Jean-Benoit Rossel
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Melanie Boand
- Department of Anesthesia, CHUV, Lausanne, Vaud, Switzerland
| | - Alain Farron
- Department of Orthopedic Surgery, CHUV, Lausanne, Vaud, Switzerland
| | - Eric Albrecht
- Department of Anesthesia, CHUV, Lausanne, Vaud, Switzerland
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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Breebaart MB, Branders J, Sermeus L, Termurziev S, Camerlynck H, Van Putte L, Van Putte Minelli M, De Hert S. Levobupivacaine Consumption in Automated Intermittent Bolus in Ultrasound Guided Subparaneural Sciatic Nerve Catheters: A Prospective Double-Blind Randomized Trial. Local Reg Anesth 2021; 14:43-50. [PMID: 33790643 PMCID: PMC8007557 DOI: 10.2147/lra.s299870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Continuous sciatic nerve blocks have proven benefits for postoperative analgesia after foot surgery. However, the optimal mode of administration remains a point of debate. Ultrasound guided subparaneural injection accelerates onset time and increases duration after a single shot sciatic nerve block. This double blind prospective randomized trial compares the 48-hour local anesthetic (LA) dose consumption of an automated intermittent bolus technique to a continuous infusion regimen in a subparaneural sciatic nerve catheter after hallux valgus surgery. Patients and Methods Patients scheduled for hallux valgus surgery were randomized to receive either a continuous infusion of levobupivacaine 0.125% at 5mL/h (group A) or an intermittent automated bolus of 9.8 mL every 2 hours with a background of 0.1 mL/h (group B), both with a PCA bolus of 6 mL and lockout of 30 minutes. The 48 hour LA consumption, PCA boluses, Numeric Rating Scale (NRS), satisfaction and return of normal sensation were recorded. Results Sixteen patients were excluded because of protocol violation or technical problems and 42 patients remained for analysis. The 48 hour ropivacaine consumption was higher in group A (293 ±60 mL) than group B (257±33 mL). The median and highest NRS scores and patient satisfaction were not statistically different between groups. Normal sensation returned after 75 ± 22 hours (group A) and 70 ± 17 hours (group B). Conclusion Programmed bolus administration in subparaneural sciatic nerve catheters reduces LA consumption 48 hours after surgery with equal analgesia and patient satisfaction. Return of sensation is variable and can last more than 75 hours.
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Affiliation(s)
- Margaretha B Breebaart
- Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium.,Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Jordi Branders
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Luc Sermeus
- Department of Anesthesiology, St. Luc University Hospital, Brussels, Belgium
| | - Sultan Termurziev
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Helene Camerlynck
- Department of Anesthesia, Antwerp University Hospital, Edegem, Belgium
| | - Lennert Van Putte
- Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium
| | | | - Stefan De Hert
- Department of Anesthesia and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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Albrecht E, Reynvoet M, Fournier N, Desmet M. Dose–response relationship of perineural dexamethasone for interscalene brachial plexus block: a randomised, controlled, triple‐blind trial. Anaesthesia 2019; 74:1001-1008. [DOI: 10.1111/anae.14650] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- E. Albrecht
- Department of Anaesthesia Lausanne University Hospital LausanneSwitzerland
| | - M. Reynvoet
- Department of Anaesthesia AZ Groeninge KortrijkBelgium
| | - N. Fournier
- Institute of Social and Preventive Medicine Lausanne University Hospital Lausanne Switzerland
| | - M. Desmet
- Department of Anaesthesia AZ Groeninge KortrijkBelgium
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Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract 2012; 2012:560879. [PMID: 22761615 PMCID: PMC3385590 DOI: 10.1155/2012/560879] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 12/29/2022] Open
Abstract
A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.
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Affiliation(s)
- José Aguirre
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Alicia Del Moral
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Irina Cobo
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Alain Borgeat
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Stephan Blumenthal
- Department of Anesthesiology, Triemli Hospital, 8063 Zurich, Switzerland
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Ortiz de la Tabla González R, Martínez Navas A. [Influence of femoral catheter stimulation intensity on post-surgical analgesia after total knee replacement]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:187-196. [PMID: 22542876 DOI: 10.1016/j.redar.2012.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 02/15/2012] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Stimulating catheters allow the catheter point to be positioned near the nerve, thus reducing the amount of local anaesthetic required for a successful block. There is currently a debate on what is the stimulation intensity required to provide adequate analgesia, although it does seem that if it is obtained with 1mAmp or less the block is more effective. The objective of the study was to demonstrate whether different neurostimulation intensities with the stimulating catheter at femoral nerve level, had an influence on the adequacy of post-surgical analgesia during the 48h after total knee arthroplasty. MATERIAL AND METHODS A comparative, prospective and randomised study was conducted on patients subjected to total knee replacement. After surgery with subarachnoid anaesthesia, a continuous femoral block was performed with a stimulating catheter at a neurostimulation intensity 0.2 and 0.5mAmp in Group 1, between 0.6 and 1mAmp in Group 2, equal or higher than 1.1mAmp in Group 3, and in Group 4 the catheter was introduced between 3-5cm without looking for a motor response. A dose of 0.2% ropivacaine 0.4mL/kg and an infusion at 5mL/h, with boluses of 10mL/30min, was administered via the catheter. Sciatic nerve block was also performed on all patients with 20ml of 0.5% ropivacaine. The patient demographics were recorded, as well as, post-surgical analgesia details, sensory and motor block in each area, boluses requested, rescue analgesia, and undesirable effects at 8, 16, 24, 36 and 48h. RESULTS A total of 124 patients were included, 32 in Group 1 (25.8%), 21 in Group 2 (16.9%), 31 in Group 3 (25%), and 40 in group 4 (32.3%). The 4 groups were homogeneous as regards age, height, weight and ASA. There were no statistically significant differences found in the post-operative pain, except during movement in the femoral area at 36 hours (p=.032). There were also no statistically significant differences found in the sensory block in the femoral area at 48 hours (p=.019) and in the femoral cutaneous nerve block at 8 hours (p=.049) or at 24 hours (p=.045). As regards motor block, differences were only found in the obturator nerve at 24 hours (p=.016). There were no differences in rescue analgesia, patient controlled analgesia (PCA) boluses requested or administered, except that the number of boluses requested at 16 hours was less in Group 3 (p=.049). There were also no significant differences in undesirable effects or in the level of satisfaction of the patients between the four groups. CONCLUSIONS In our study, no influence was found on the level of analgesia provided after knee replacement surgery with the neurostimulation intensity to which the neuromuscular system involved responded when a stimulating catheter is inserted at femoral level.
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de José María B, Banús E, Navarro-Egea M, Banchs RJ. Tips and tricks to facilitate ultrasound-guided placement of peripheral nerve catheters in children. Paediatr Anaesth 2011; 21:974-9. [PMID: 21535299 DOI: 10.1111/j.1460-9592.2011.03598.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To describe an approach to facilitate ultrasound (US)-guided placement of peripheral nerve catheters in children. BACKGROUND Continuous peripheral nerve blocks (CPNB) provide excellent surgical anesthesia and postoperative analgesia. However, catheters can be difficult to place, especially in children. METHODS Ten US-guided peripheral nerve catheters were placed and placement difficulties encountered were recorded. Four series of 15 consecutive US-guided CPNB were then performed, adding in each series one possible solution to each of the troubles previously encountered. Finally, all maneuvers were employed in the placement of 15 US-guided CPNB in children 3-10 years old and then followed clinically. RESULTS Initial difficulties encountered were as follows: (i) introducing the catheter, (ii) catheter tip visualization, (iii) length of catheter to be introduced, and (iv) catheter fixation and appropriate long-lasting dressing. The proposed facilitating procedure that addresses each of these difficulties is as follows: (i) three-hand technique: an assistant's hand holds the US transducer, the proceduralist anesthetist slightly withdraws and rotates the needle tip with one hand and advances the catheter with the other, (ii) needle visualization in long axis (LAX) whenever possible with catheter placed inside the needle and US guidance of spread of local anesthetic (LA) through the catheter, (iii) catheter advanced until resistance is found or up to a maximum of 5 cm, and (iv) subcutaneous tunneling of the catheter, Dermabond glue, and careful transparent dressing. All catheters in the last series were 100% effective during surgery and provided complete analgesia for ≥3 days without complications. CONCLUSIONS Continuous peripheral nerve blocks in children should be placed under US guidance in LAX whenever possible, with a three-hand technique and slightly withdrawing or rotating the needle tip to introduce the catheter, administering LA through the catheter, and performing subcutaneous tunneling and careful dressing.
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Affiliation(s)
- Belén de José María
- Department of Anaesthesiology, Sant Joan de Déu Women and Children's Hospital, University of Barcelona, Via Augusta 337, Barcelona, Spain.
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Abstract
A single-injection peripheral nerve block using long-acting local anesthetic provides analgesia for 12 to 24 hours; however, many surgical procedures result in pain that lasts far longer. One relatively new option is a continuous peripheral nerve block (CPNB): local anesthetic is perfused via a perineural catheter directly adjacent to the peripheral nerve(s) supplying the surgical site, providing potent, site-specific analgesia. CPNB results in decreased pain, opioid requirements, opioid-related side effects, and sleep disturbances; in some cases, accelerating resumption of tolerated passive joint range-of-motion and increasing patient satisfaction. Ambulatory perineural infusion may be provided using a portable infusion pump, in some cases resulting in decreased hospitalization duration and related costs. Serious complications are rare, but may result in significant morbidity.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103-8770, USA.
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Ilfeld BM, Sandhu NS, Loland VJ, Madison SJ, Suresh PJ, Mariano ER, Bishop ML, Schwartz AK, Lee DK. Ultrasound-guided (needle-in-plane) perineural catheter insertion: the effect of catheter-insertion distance on postoperative analgesia. Reg Anesth Pain Med 2011; 36:261-5. [PMID: 21519311 PMCID: PMC3085850 DOI: 10.1097/aap.0b013e31820f3b80] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle in plane and nerve in short axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to-nerve contact during the subsequent perineural infusion, leading to inferior analgesia. Although a potential solution may appear obvious-advancing the catheter tip only to the tip of the needle, leaving the catheter tip at the target nerve-this technique has not been prospectively evaluated. We therefore hypothesized that during needle in-plane ultrasound-guided perineural catheter placement, inserting the catheter a minimum distance (0-1 cm) past the needle tip is associated with improved postoperative analgesia compared with inserting the catheter a more traditional 5 to 6 cm past the needle tip. METHODS Preoperatively, subjects received a popliteal-sciatic perineural catheter for foot or ankle surgery using ultrasound guidance exclusively. Subjects were randomly assigned to have a single-orifice, flexible catheter inserted either 0 to 1 cm (n = 50) or 5 to 6 cm (n = 50) past the needle tip. All subjects received a single-injection mepivacaine (40 mL of 1.5% with epinephrine) nerve block via the needle, followed by catheter insertion and a ropivacaine 0.2% infusion (basal 6 mL/hr, bolus 4 mL, 30-min lockout), through at least the day after surgery. The primary end point was the average surgical pain as measured with a 0- to 10-point numeric rating scale the day after surgery. Secondary end points included time for catheter insertion, incidence of catheter dislodgement, maximum ("worst") pain scores, opioid requirements, fluid leakage at the catheter site, and the subjective degree of an insensate extremity. RESULTS Average pain scores the day after surgery for subjects of the 0- to 1-cm group were a median of 2.5 (interquartile range, 0.0-5.0), compared with 2.0 (interquartile range, 0.0-4.0) for subjects of the 5- to 6-cm group (P = 0.42). Similarly, among the secondary end points, no statistically significant differences were found between the 2 treatment groups. There was a trend of more catheter dislodgements in the minimum-insertion group (5 vs 1; P = 0.20). CONCLUSIONS This study did not find evidence to support the hypothesis that, for popliteal-sciatic perineural catheters placed using ultrasound guidance and a needle-in-plane technique, inserting the catheter a minimum distance (0-1 cm) past the needle tip improves (or worsens) postoperative analgesia compared with inserting the catheter a more traditional distance (5-6 cm). Caution is warranted if extrapolating these results to other catheter designs, ultrasound approaches, or anatomic insertion sites.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, CA, USA.
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Pelissier P, Svartz L, Rakotondriamihary S, Nouette-Gaulin K, Dousset V. [Postoperative analgesia with continuous intra-articular infusion of ropivacaine following trapeziectomy]. ACTA ACUST UNITED AC 2008; 27:222-6. [PMID: 18930428 DOI: 10.1016/j.main.2008.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 08/11/2008] [Accepted: 08/22/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVES A pilot study was implemented to evaluate the efficacy of patient controlled analgesia (PCA) with continuous intra-articular infusion of ropivacaine following trapeziectomy with ligament reconstruction and tendon interposition. METHODS Twelve patients were prospectively included. A catheter was placed into the trapezium void and connected to a PCA pump set on a continuous intra-articular infusion rate of ropivacaine: 2mg/ml. Patients were allowed to deliver additional boluses when analgesia was incomplete. RESULTS Pain was evaluated less than 3/10 (Numeric Scale Evaluation) by 92% of the patients during the first 48 h. No toxicity of the local anaesthetic nor catheter-related complication were reported. CONCLUSION This preliminary study showed continuous basal and bolus infusion of ropivacaine through a single catheter placed into the trapezium void to provide an excellent postoperative pain control and to be related to a high patient's satisfaction level.
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Affiliation(s)
- P Pelissier
- Service de chirurgie plastique-main, centre F.-X.-Michelet, groupe hospitalier Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux, France.
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Bryan NA, Swenson JD, Greis PE, Burks RT. Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications. J Shoulder Elbow Surg 2007; 16:388-95. [PMID: 17507247 DOI: 10.1016/j.jse.2006.10.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2006] [Revised: 10/09/2006] [Accepted: 10/22/2006] [Indexed: 02/01/2023]
Abstract
Indwelling interscalene catheters are utilized for inpatient postoperative pain control after shoulder surgery. Improved medical equipment and advanced techniques may allow safe and efficacious outpatient use. One hundred and forty-four consecutive indwelling interscalene catheter placements were reviewed to determine adverse events, complications, and efficacy. Real-time ultrasound-guided catheter placement technique is described. Post-anesthesia care unit (PACU) narcotic consumption and last recorded pain score were reviewed to gauge efficacy. The catheter placement technique was 98% successful. There were 14 (9.7%) minor adverse events including inadequate analgesia (8), accidental catheter removal (4) of disconnection (1), and shortness of breath (1). The single complication (0.7%) was a small apical pneumothorax. The average PACU narcotic consumption in intravenous morphine equivalents was 1.7 mg. The average last recorded PACU pain score on a scale of 1 to 10 was 0.6. Catheter placement under real-time ultrasound guidance is accurate. Outpatient use of indwelling interscalene catheters is safe and efficacious.
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Affiliation(s)
- Nathaniel A Bryan
- Department of Orthopedics, University of Utah, Salt Lake City, UT 84108, USA.
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Banks A. Innovations in Postoperative Pain Management: Continuous Infusion of Local Anesthetics. AORN J 2007; 85:904-14; quiz 915-8. [PMID: 17499054 DOI: 10.1016/j.aorn.2007.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients and health care providers alike struggle with alleviating postoperative pain. Patients with unrelieved pain are less likely to cough, breathe deeply, or move easily after surgery, which adversely affects their recovery. Innovations in technology, such as continuous infusion of local anesthetics, have revolutionized postoperative pain management. Technological improvements in needles, catheter insertion techniques, and effortless drug delivery systems are facilitating prolonged analgesia with few adverse effects, increasing patient satisfaction, and expediting postoperative recovery.
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Tsui BCH, Bury J, Bouliane M, Ganapathy S. Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery. Acta Anaesthesiol Scand 2007; 51:255-60. [PMID: 17096670 DOI: 10.1111/j.1399-6576.2006.1184.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous cervical epidural anesthesia can provide excellent peri- and post-operative analgesia, although several factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low-current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. METHODS After Institutional Review Board approval, adult patients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1-10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch responses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2-8 ml/h) of ropivacaine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. RESULTS Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8 +/- 2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4-7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. CONCLUSION This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.
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Affiliation(s)
- B C H Tsui
- Departments of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Edmonton, Alberta, Canada.
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Hayek SM, Ritchey RM, Sessler D, Helfand R, Samuel S, Xu M, Beven M, Bourdakos D, Barsoum W, Brooks P. Continuous femoral nerve analgesia after unilateral total knee arthroplasty: stimulating versus nonstimulating catheters. Anesth Analg 2006; 103:1565-70. [PMID: 17122240 PMCID: PMC1764632 DOI: 10.1213/01.ane.0000244476.38588.c9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Continuous femoral analgesia provides extended pain relief and improved functional recovery for total knee arthroplasty (TKA). Stimulating catheters may allow more accurate placement of catheters. METHODS We performed a randomized prospective study to investigate the use of stimulating catheters versus nonstimulating catheters in 41 patients undergoing TKA. All patients received i.v. patient-controlled anesthesia for supplementary pain relief. The principal aim of the trial was to examine whether a stimulating catheter allowed the use of lesser amounts of local anesthetics than a nonstimulating catheter. The additional variables we examined included postoperative pain scores, opioid use, side effects, and acute functional orthopedic outcomes. RESULTS Analgesia was satisfactory in both groups, but there were no statistically significant differences in the amount of ropivacaine administered; the median amount of ropivacaine given to patients in the stimulating catheter group was 8.2 mL/h vs 8.8 mL/h for patients with nonstimulating catheters, P = 0.26 (median difference -0.6; 95% confidence interval, -2.3 to 0.6). No significant differences between the treatment groups were noted for the amount of fentanyl dispensed by the i.v. patient-controlled anesthesia, numeric pain rating scale scores, acute functional orthopedic outcomes, side effects, or amounts of oral opioids consumed. CONCLUSION The use of stimulating catheters in continuous femoral nerve blocks for TKA does not offer significant benefits over traditional nonstimulating catheters.
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Affiliation(s)
- Salim M Hayek
- Department of Pain Management, The Cleveland Clinic, Cleveland, Ohio, USA.
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15
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Casati A, Fanelli G, Danelli G, Baciarello M, Ghisi D, Nobili F, Chelly JE. Stimulating or conventional perineural catheters after hallux valgus repair: a double-blind, pharmaco-economic evaluation. Acta Anaesthesiol Scand 2006; 50:1284-9. [PMID: 17067330 DOI: 10.1111/j.1399-6576.2006.01101.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND We prospectively evaluated direct analgesia-related costs of continuous sciatic nerve block using either a stimulating or conventional catheter after hallux valgus repair. METHODS The perineural catheter was inserted through a stimulating introducer either blindly (group Conventional, n= 38) or while stimulating via the catheter (group Stimulating, n= 38). Nerve block was induced with 25 ml of mepivacaine 15 mg/ml, and was followed 3 h later by a patient-controlled infusion of ropivacaine 2 mg/ml (basal infusion: 3 ml/h; incremental dose: 5 ml; lock-out time: 30 min). Rescue tramadol [100 mg intravenous (i.v.)] was given if required. Local anesthetic consumption, need for rescue tramadol and post-operative nausea and vomiting (PONV) treatment, and patient's satisfaction were recorded during first 24-h infusion. Cost calculations were based on the acquisition cost of drugs and devices. RESULTS Both techniques were similarly effective, but local anesthetic consumption and need for rescue analgesics were lower in the Stimulating group [respectively, 120 vs. 153 ml (P= 0.004) and 21% vs. 60% (P= 0.001)]. The analgesia-related costs for 24 h were similar when 100-ml bags of ropivacaine 2 mg/ml were used (66 euro vs. 67 euro; P= 0.26). When 200-ml bags of ropivacaine were used, the analgesia-related costs were higher in the Stimulating group than the Conventional group (75 euro vs. 55 euro; P= 0.0005). CONCLUSIONS Direct costs of continuous sciatic nerve block ranged from 55 to 75 euro. Stimulating catheters reduced local anesthetic consumption and need for rescue analgesics. This was only cost effective when 100-ml bags of 2 mg/ml ropivacaine were used, while the cheapest combination was the use of conventional catheters and 200-ml bags of ropivacaine.
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Affiliation(s)
- A Casati
- Department of Anesthesiology and Pain Therapy, University of Parma, Parma, Italy.
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16
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Buckenmaier CC, Auton AA, Flournoy WS. Continuous peripheral nerve block catheter tip adhesion in a rat model. Acta Anaesthesiol Scand 2006; 50:694-8. [PMID: 16987364 DOI: 10.1111/j.1399-6576.2006.01051.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous peripheral nerve block (CPNB) has been used effectively in combat casualties from Iraq and Afghanistan to provide surgical anesthesia and extended duration analgesia during evacuation and convalescence. Little information is available concerning catheter tip tissue reaction with prolonged use. METHODS Forty-eight male Sprague-Dawley rats were assigned (12 per group) to one of four catheter tip designs provided by Arrow International: group A, 20-gauge catheter with three side-holes and a bullet-shaped tip; group B, 19-gauge StimuCath catheter with coiled omni-port end with hemispherical distal tip; group C, 19-gauge catheter with single end-hole in conducting tip; group D, 19-gauge catheter with closed conducting tip with four side-holes. Following laparotomy, a randomly assigned catheter tip was sutured to the parietal peritoneal wall with the tip extending between experimental injuries created on the abdominal wall and cecum. After 7 days in situ, the catheter tips were removed from the adhesion mass using a force gauge, and the grams of force needed for removal were recorded. RESULTS The mean force +/- standard deviation values were 1.09 +/- 1.21 g for group A, 21.20 +/- 30.15 g for group B, 0.88 +/- 1.47 g for group C and 1.60 +/- 2.50 g for group D. The variation of each catheter group mean force compared with that of group B was significant (P < 0.05). There was no significant difference in adhesion force between groups A, C and D. CONCLUSIONS These results suggest that the manufactured design of a CPNB catheter tip can contribute to the adhesion of the tip in an intense inflammatory environment. This finding may have important clinical implications for CPNB catheters left in place for extended periods of time.
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Affiliation(s)
- C C Buckenmaier
- Army Regional Anesthesia and Pain Management Initiative, Walter Reed Army Medical Center, Washington DC 20307-5001, USA.
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17
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Affiliation(s)
- F Lacroix
- Département d'anesthésie et de réanimation pédiatrique, CHU Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
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Beloeil H, Gibert S, Macaire P, Zetlaoui PJ. Anesthésie locorégionale périphérique : monitorage et surveillance. ACTA ACUST UNITED AC 2006; 25:104-12. [PMID: 16226005 DOI: 10.1016/j.annfar.2005.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- H Beloeil
- Département d'anesthésie-réanimation, hôpital de Bicêtre, 48, rue du Général-Leclerc, 94270 Le-Kremlin-Bicêtre cedex, France
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De Andrés J, Alonso-Iñigo JM, Sala-Blanch X, Reina MA. Nerve stimulation in regional anesthesia: theory and practice. Best Pract Res Clin Anaesthesiol 2005; 19:153-74. [PMID: 15966491 DOI: 10.1016/j.bpa.2004.11.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is now an accumulation of extensive and varied experience with the use of electrical stimulation for verifying the close approximation of needle and nerve, and for increasing the corresponding success rate. The application of this experience has been of proven benefit in the teaching of regional anesthetic techniques, in the performing of difficult nerve blocks, and in the use of novel accesses, resulting in decreased morbidity and a reduced requirement for local anesthetic. Nerve stimulation can also be used in uncooperative patients and in anesthetized individuals or patients under the effects of CNS depressors, although the risk of intraneural injection of local anesthetic is not eliminated in such cases. Putting the accummulated knowledge into practice is not simply a question of using electrical stimulation to elicite an artificial muscle contraction. Sound knowledge of the anatomy of the area to be blocked, the muscle territory subsidiary to the nerve in question, the applied neurophysiology, and the pharmacology of the local anesthetic used are needed. This chapter reviews the most important aspects, from nerve anatomy and physiology, to electrical features of the needle, and devices used for the updated clinical application of nerve stimulation in the practice of plexus regional anesthesia.
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Affiliation(s)
- Jose De Andrés
- Valencia University Medical School, Department of Anesthesiology and Critical Care.
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20
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Prusinkiewicz C, Lang S, Tsui BCH. Lateral cervical epidural catheter placement using nerve stimulation for continuous unilateral upper extremity analgesia following a failed continuous peripheral nerve block. Acta Anaesthesiol Scand 2005; 49:579-82. [PMID: 15777311 DOI: 10.1111/j.1399-6576.2005.00630.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This case report describes the application of electrical stimulation (Tsui test) to confirm placement of a cervical epidural catheter for postoperative pain management in a patient with a failed brachial plexus block who underwent upper extremity surgery. An epidural catheter was easily advanced under nerve stimulation guidance to the surgical dermatome C4 level without any resistance from the C7-T1 level. Successful analgesia was achieved with a bolus of 2 mg ml(-1) ropivacaine 2 ml and fentanyl 20 microg, followed by a continuous infusion of 2 mg ml(-1) ropivacaine with 2 microg ml(-1) of fentanyl at a rate of 2 ml h(-1). This case reminds the clinician that cervical epidural analgesia may serve as an alternative to a difficult continuous peripheral nerve block. Electrical stimulation may also help to confirm cervical epidural catheter placement at the appropriate dermatome to provide effective analgesia with minimal side-effects.
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Affiliation(s)
- C Prusinkiewicz
- Department of Anesthesia, University of Calgary, and Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Martínez Navas A, Vázquez Gutierrez T, Echevarría Moreno M. Continuous lateral popliteal block with stimulating catheters. Acta Anaesthesiol Scand 2005; 49:261-3. [PMID: 15715632 DOI: 10.1111/j.1399-6576.2004.00574.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Foot surgery often induces severe postoperative pain. Sciatic nerve block is a good alternative for its treatment. We report two cases of continuous lateral popliteal sciatic nerve block using two different stimulating catheters. The lateral approach may offer some advantages. Stimulating catheters may be useful to verify correct catheter tip positioning. This technique seem to be easy to use and provided excellent pain relief.
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