BACKGROUND:Bilateral paravertebral block (PVB) is a suitable alternative to thoracic epidural analgesia (TEA) for abdominal surgeries. This randomized clinical trial aims to determine if PVB is ...noninferior to TEA in terms of analgesia after midline laparotomy.
METHODS:Seventy American Society of Anesthesiologists (ASA) class I–III patients undergoing a laparotomy through a midline incision were randomized to receive either TEA (TEA group) or continuous bilateral PVB (PVB group) as a part of a multimodal analgesia regimen in an open-label design. Noninferiority was to be concluded if the mean between-group difference in pain on movement at the 24 postoperative hours was within a margin of 2 points on a 0–10 numerical rating scale (NRS). Pain score at rest and on movement, analgesic consumption, hemodynamics, and adverse events during the first 72 postoperative hours were the secondary outcome measures assessed for superiority. Postblock and steady-state plasma concentrations of ropivacaine and pattern of dye spread were also recorded in the PVB group.
RESULTS:The primary outcome of pain scores on movement at 24 postoperative hours was noninferior in PVB group in comparison to TEA group (mean difference 95% confidence interval {CI}, 0.43 −0.72–1.58). The pain scores at rest and on movement at other time points of assessment were within clinically acceptable limits in both groups with no significant differences between the groups over time. Arterial plasma ropivacaine levels were within safe limits, while steady-state venous level was higher than an acceptable threshold in 9 of 34 cases.
CONCLUSIONS:As a component of multimodal analgesia, bilateral PVB provides noninferior analgesia compared to TEA for midline laparotomy.
Although the stellate ganglion is located anteriorly to the first rib, anesthetic block is routinely performed at the C6 level. Ultrasonography allegedly improves accuracy of needle placement and ...spread of injectate. The technique is relatively new, and the optimal approach has not been determined. Moreover, the location of the cervical sympathetic trunk relative to the prevertebral fascia is debatable.
Three-dimensional sonography was performed on 10 healthy volunteers, and image reconstruction was completed. On the basis of analysis of pertinent anatomy, a lateral trajectory for needle placement was simulated. Accuracy was tested by injection of methylene blue in cadavers. A clinical validation study was then conducted. A block needle was inserted according to the predetermined lateral path, and 5 mL of a mixture of bupivacaine and iohexol was injected. Spread of the contrast agent was verified fluoroscopically.
Image reconstruction revealed that the cervical sympathetic trunk is located posterolaterally to the prevertebral fascia on the surface of the longus colli muscle. The mean anteroposterior width of the muscle at the C6 level was 11 mm. The lateral approach does not interfere with any visceral or nerve structures. Anatomic dissection in cadavers confirmed entirely subfascial spread of the dye and staining of the sympathetic trunk. The contrast agent spread was seen in all patients between the C4 and T1 levels in a typical prevertebral pattern.
This study revealed that, at the C6 level, the cervical sympathetic trunk lies entirely subfascially. Subfascial injection via the lateral approach ensures reliable spread of a solution to the stellate ganglion.
Purpose
During peripheral nerve block procedures, needle visibility decreases as the angle of needle insertion relative to skin increases due to loss of reflective signals. The primary aim of our ...study was to compare the effect of beam steering on the visibility of echogenic and non-echogenic block needles.
Methods
PAJUNK
®
non-echogenic and echogenic needles were inserted into pork meat at 20°, 40°, 60°, and 70° angles, and electronic beam steering was applied at three different angles (shallow, medium, and steep) to obtain the best possible needle images. Eleven anesthesiologists blinded to the type of needle or use of beam steering scored the images obtained (0 = needle not visible; 10 = excellent needle shaft and tip visibility). Mean scores were used to classify the needles as poor visibility (mean score 0-3.3), intermediate visibility (mean score 3.4-6.6), or good visibility (mean score 6.7-10).
Results
At 20°, the visibility scores were intermediate to good in all groups. At 40°, the mean (SD) visibility score for the non-echogenic needle improved significantly from 3.1 (1.4) to 7.9 (1.8) with application of beam steering (difference = 4.8; 95% confidence interval CI: 3.1 to 6.6;
P
< 0.001). At 60°, the mean (SD) visibility score for the non-echogenic needle was poor 0.6 (0.7) and remained poor 2.4 (1.1) with beam steering. One the other hand, the echogenic needle without beam steering 6.5 (1.8) scored significantly better than the non-echogenic needle with beam steering 2.4 (1.1) (difference = 4.2; 95% CI: 2.7 to 5.6;
P
< 0.001). At 70°, the mean needle visibility score was poor for the non-echogenic needle with or without beam steering. In contrast, the echogenic needle attained an intermediate visibility score with or without beam steering. Beam steering did not significantly change the visibility scores of either the echogenic or the non-echogenic needle (
P
= 0.088 and 0.056, respectively) at a 70° angle.
Conclusion
The PAJUNK echogenic needle, with or without beam steering, was more visible when compared with the non-echogenic needle at 60° and 70° angles of insertion. In contrast, at a 40° angle of needle insertion, the non-echogenic needle with beam steering was more visible compared with the echogenic needle.
Pain following arthroplasty is managed utilizing continuous peripheral nerve blocks (PNB) or local infiltration analgesia (LIA). The current economic climate in many countries requires discharge from ...the hospital within a couple of days following arthroplasty. Earlier studies had documented the efficacy of LIA for lower limb arthroplasty with preserved motor function and early rehabilitation, but some recent studies fail to confirm such a benefit. The motor block associated with PNB can be challenging with well tolerated rehabilitation. This review will discuss the efficacy and safety of these two analgesic techniques.
LIA facilitates early rehabilitation with total knee joint arthroplasty but such a benefit may not be obvious with total hip arthroplasty in the presence of multimodal analgesia. LIA data are very diverse depending on drugs injected, site of catheters, drug dosing and use of adjuvants. Chondrolysis documented with shoulder surgery with LIA is not a concern as there is no cartilage left with arthroplasty except in uniknees. Unpredictable motor weakness poses challenge with lower limb nerve blocks.
More rigorously conducted large-scale comparative studies are required to document the relative safety and efficacy of these two analgesic techniques. Standardization of infiltration techniques, catheter location, drugs and dosing are much needed. LIA with extended duration long-acting local anesthetic is in its infancy and may be an alternative to PNBs.
Local infiltration analgesia Ganapathy, Sugantha; Brookes, Jonathan; Bourne, Robert
Anesthesiology clinics,
06/2011, Letnik:
29, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Pain after major abdominal, orthopedic, and thoracic surgeries can be significant causing unacceptable morbidity. Poorly controlled pain results in patient dissatisfaction and may also be associated ...with major morbidities, including perioperative myocardial ischemia, pulmonary complications, altered immune function, and postoperative cognitive dysfunction. Various techniques are currently used to manage this pain, and opioids are amongst the most frequently used. Recent literature supports the use of regional anesthesia in the form of various peripheral nerve blocks as a better alternative. This article discusses the role and evidence for wound infiltration analgesia in general surgery, orthopedic surgery, neurosurgery, and thoracic surgery.
The primary objective of this study was to compare the analgesic efficacy of combined suprascapular and axillary nerve block (SSAX) with interscalene block (ISB) after arthroscopic shoulder surgery. ...Our hypothesis was that ultrasound-guided SSAX would provide postoperative analgesia equivalent to ISB.
Sixty adult patients undergoing arthroscopic shoulder surgery received either SSAX or ISB prior to general anesthesia, in a randomized fashion. Pain scores, satisfaction, and adverse effects were recorded in the recovery room, 6 hours, 24 hours, and 7 days after surgery.
Combined suprascapular and axillary nerve block provided nonequivalent analgesia when compared with ISB at different time points postoperatively, except on postoperative day 7. Interscalene block had better mean static pain score in the recovery room (ISB 1.80 95% confidence interval CI, 1.10-2.50 vs SSAX 5.45 95% CI, 4.40-6.49; P < 0.001). At 24 hours, SSAX had better mean static pain score (ISB 6.35 95% CI, 5.16-7.54 vs SSAX 3.92 95% CI, 2.52-5.31; P = 0.01) with similar satisfaction between the groups.
Combined suprascapular and axillary nerve block provides nonequivalent analgesia compared with ISB after arthroscopic shoulder surgery. While SSAX provides better quality pain relief at rest and fewer adverse effects at 24 hours, ISB provides better analgesia in the immediate postoperative period. For arthroscopic shoulder surgery, SSAX can be a clinically acceptable analgesic option with different analgesic profile compared with ISB.
Chronic postsurgical pain (CPSP) following nonarthroplasty orthopedic surgery has a variable incidence and results in significant morbidity in patients. The etiology of this persisting pain could be ...because of a variety of insults during surgery including injuries to nerves and release of inflammatory mediators. Trauma is well known to result in complex regional pain syndrome (CRPS). Phantom limb pain frequently follows both traumatic and ischemic amputations. Both these conditions are well known to result in debilitating pain. Management of CPSP is not only dependent on careful planning of acute pain management but also the treatment of established pain. Preventive strategies include use of multimodal analgesia, preventing opioid-induced hyperalgesia, and use of regional blocks. Treatment of established CPSP will depend on its etiology. Phantom pain and CRPS can be difficult to treat once established. Many therapeutic interventions have been tried with variable success.
Bilateral paravertebral block (PVB) is a suitable alternative to thoracic epidural analgesia (TEA) for abdominal surgeries. This randomized clinical trial aims to determine if PVB is noninferior to ...TEA in terms of analgesia after midline laparotomy.
Seventy American Society of Anesthesiologists (ASA) class I-III patients undergoing a laparotomy through a midline incision were randomized to receive either TEA (TEA group) or continuous bilateral PVB (PVB group) as a part of a multimodal analgesia regimen in an open-label design. Noninferiority was to be concluded if the mean between-group difference in pain on movement at the 24 postoperative hours was within a margin of 2 points on a 0-10 numerical rating scale (NRS). Pain score at rest and on movement, analgesic consumption, hemodynamics, and adverse events during the first 72 postoperative hours were the secondary outcome measures assessed for superiority. Postblock and steady-state plasma concentrations of ropivacaine and pattern of dye spread were also recorded in the PVB group.
The primary outcome of pain scores on movement at 24 postoperative hours was noninferior in PVB group in comparison to TEA group (mean difference 95% confidence interval {CI}, 0.43 -0.72-1.58). The pain scores at rest and on movement at other time points of assessment were within clinically acceptable limits in both groups with no significant differences between the groups over time. Arterial plasma ropivacaine levels were within safe limits, while steady-state venous level was higher than an acceptable threshold in 9 of 34 cases.
As a component of multimodal analgesia, bilateral PVB provides noninferior analgesia compared to TEA for midline laparotomy.
The objective of this study was to investigate the extent of dermatomal spread following an ultrasound-guided thoracic paravertebral block (PVB) when equal volumes of local anesthetic are injected at ...1 versus 5 vertebral levels.
Seventy patients undergoing a unilateral mastectomy were randomized to receive either single or multiple injections of a PVB under real-time ultrasound guidance using a parasagittal approach. The patients in the single-injection group received a PVB at T3-T4 level with 25 mL of 0.5% ropivacaine and 4 subcutaneous sham injections. Patients in the multiple-injection group received 5 injections of a PVB from T1 to T5 level. Five milliliters of 0.5% ropivacaine was injected at each level. Evaluation of the sensory block was carried out 20 minutes following the completion of the PVB.
The median (interquartile range) dermatomal spread was not significantly different for the single-injection group (5 4-6) compared with the multiple-injection group (5 5-6), with a median difference of 0 segments (95% confidence interval, -1 to 0 segments; P = 0.22). The median time to performance of the single-injection PVB was shorter compared with the multiple-injection group (10 minutes), with a mean difference of -4 minutes (95% confidence interval, -6 to -3 minutes; P < 0.001).
An ultrasound-guided single-injection PVB provides equivalent dermatomal spread and duration of analgesia compared with a multiple-injection PVB. The single-injection technique takes less time to perform and hence may be preferred over a multiple-injection technique.The trial was registered prospectively at ClinicalTrials.gov (NCT02852421) on July 15, 2016.
PDF
