RESUMEN
Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.
Asunto(s)
Bloqueo Nervioso/métodos , Pared Torácica , Ultrasonografía Intervencional/métodos , HumanosRESUMEN
Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.
Asunto(s)
Dolor Agudo/tratamiento farmacológico , Anestesia de Conducción/métodos , Manejo del Dolor/métodos , HumanosRESUMEN
Serratus anterior plane and pectoral nerves blocks are recently described alternatives to established regional anaesthesia techniques in cardiac surgery, thoracic surgery and trauma. We performed a systematic review to establish the current state of evidence for the analgesic role of these fascial plane blocks in these clinical settings. We identified relevant studies by searching multiple databases and trial registries from inception to June 2019. Study heterogeneity prevented meta-analysis and studies were instead qualitatively summarised and stratified by type of surgery and comparator. We identified 51 studies: nine randomised control trials; 13 cohort studies; 19 case series; and 10 case reports. The majority of randomised controlled trials studied the serratus anterior plane block in thoracotomy or video-assisted thoracoscopic surgery, with only two investigating pectoral nerves blocks. The evidence in thoracic trauma comprised only case series and reports. Results indicate that single-injection serratus anterior plane and the pectoral nerves blocks reduce pain scores and opioid consumption compared with systemic analgesia alone in cardiothoracic surgery, cardiac-related interventional procedures and chest trauma for approximately 6-12 h. The duration of action appears longer than intercostal nerve blocks but may be shorter than thoracic paravertebral blockade. Block duration may be prolonged by a continuous catheter technique with potentially similar results to thoracic epidural analgesia. There were no reported complications and the risk of haemodynamic instability appears to be low. The current evidence, though limited, supports the efficacy and safety of serratus anterior plane and the pectoral nerves blocks as analgesic options in cardiothoracic surgery.
Asunto(s)
Bloqueo Nervioso , Nervios Torácicos , Procedimientos Quirúrgicos Cardíacos , Humanos , Bloqueo Nervioso/efectos adversos , Bloqueo Nervioso/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Procedimientos Quirúrgicos TorácicosRESUMEN
Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18-48 [0-116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.
Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/transmisión , Personal de Salud , Intubación Intratraqueal , Exposición Profesional/efectos adversos , Neumonía Viral/transmisión , Adulto , COVID-19 , Infecciones por Coronavirus/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/epidemiología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Riesgo , SARS-CoV-2RESUMEN
Surgery is the primary therapeutic intervention for breast cancer and can result in significant postoperative pain. We searched the current literature and performed a meta-analysis in order to compare the analgesic efficacy of the pectoral type-2 (Pecs II) block with systemic analgesia alone and with a thoracic paravertebral block for breast cancer surgery. Primary outcome was postoperative opioid consumption in the first 24 h after surgery. Secondary outcomes were pain scores at 0, 3, 6, 9 and 24 h after surgery, intra-operative opioid consumption, time to first analgesic request and incidence of postoperative nausea and vomiting. We identified 13 randomised controlled trials that included 815 patients. The Pecs II block significantly reduced postoperative opioid consumption (standardised difference in means: -13.64 mg oral morphine equivalents; 95%CI: -21.22 to -6.05; p < 0.01) and acute postoperative pain at all intervals in the first 24 h after surgery compared with systemic analgesia alone. Compared with the thoracic paravertebral block, the Pecs II block resulted in similar postoperative opioid consumption (standardised difference in means: -8.73 mg oral morphine equivalents; 95%CI: -18.16 to 0.69; p = 0.07) and postoperative pain scores after first measurement. In conclusion, the Pecs II block offers improved analgesic efficacy compared with systemic analgesia alone and comparable analgesic efficacy to a thoracic paravertebral block for breast cancer surgery.
Asunto(s)
Neoplasias de la Mama/cirugía , Mastectomía/efectos adversos , Bloqueo Nervioso/métodos , Dolor Postoperatorio/prevención & control , Analgésicos Opioides/administración & dosificación , Esquema de Medicación , Femenino , Humanos , Mastectomía/métodos , Dolor Postoperatorio/etiología , Nervios TorácicosRESUMEN
Regional anaesthesia is often helpful in improving respiratory function and analgesia following multiple rib fractures. The erector spinae plane block has become the technique of choice in our institution due to its relative simplicity and purported safety. The aim of this retrospective cohort study was to determine its effectiveness in improving respiratory and analgesic outcomes. We reviewed electronic medical records of patients with traumatic rib fractures admitted to a level-one trauma centre between January 2016 and July 2017, who also received erector spinae plane blocks. We analysed the following outcomes before and up to 72 h after erector spinae plane blockade: incentive spirometry volume; maximum numerical rating scale static pain scores; and 12-h opioid consumption. Pre- and post-block data were compared. We included 79 patients, 77% of whom received continuous erector spinae plane block for a mean (SD) of 3.7 (1.9) days. The majority (85%) had other associated injuries. Incentive spirometry volumes improved from 784 (694) to 1375 (667) ml (p < 0.01) during the first 24 h following erector spinae plane blockade. Pain scores were reduced from 7.7 (2.5) to 4.7 (3.2) in the first three hours (p < 0.01). Reductions in opioid consumption were observed but did not achieve statistical significance. These improvements were largely sustained for up to 72 h. Mean arterial blood pressure remained unchanged from baseline. In conclusion, erector spinae plane blocks were associated with improved inspiratory capacity and analgesic outcomes following rib fracture, without haemodynamic instability. We propose that it should be considered to be a viable alternative to other regional analgesic techniques when these are not feasible.
Asunto(s)
Inhalación/efectos de los fármacos , Bloqueo Nervioso/métodos , Dolor/etiología , Dolor/prevención & control , Fracturas de las Costillas/complicaciones , Anciano , Analgésicos Opioides/administración & dosificación , Anestésicos Locales/administración & dosificación , Anestésicos Locales/farmacología , Presión Sanguínea/efectos de los fármacos , Esquema de Medicación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor/métodos , Músculos Paraespinales , Estudios Retrospectivos , Ropivacaína/administración & dosificación , Ropivacaína/farmacología , Espirometría/métodosRESUMEN
Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre-operative bilateral ESP blocks with 20-30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24-h opioid consumption was 18.7 mg (0.0-43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0-5.0) and 2.5 (0.0-3.0) on an 11-point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2-L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra-umbilical and infra-umbilical dermatomes with a single-level injection and its relative simplicity.
Asunto(s)
Hernia Ventral/cirugía , Herniorrafia/métodos , Laparoscopía/métodos , Bloqueo Nervioso , Vértebras Torácicas , Abdomen/cirugía , Músculos Abdominales , Dolor Abdominal/etiología , Dolor Abdominal/terapia , Anciano de 80 o más Años , Analgesia , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestésicos/administración & dosificación , Anestésicos/farmacocinética , Cadáver , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Morfina/uso terapéutico , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
We performed bilateral transmuscular quadratus lumborum blocks in six cadavers using iodinated contrast and methylene blue. Computed tomography imaging was performed in four cadavers and anatomical dissection was completed in five. This demonstrated spread to the lumbar paravertebral space in 63% of specimens, laterally to the transversus abdominis muscle in 50% and caudally to the anterior superior iliac spine in 63% of specimens. There was no radiographic evidence of spread to the thoracic paravertebral space. Anatomical dissection revealed dye staining of the upper branches of the lumbar plexus and the psoas major muscle in 70% of specimens. Further clinical studies are required to confirm if the quadratus lumborum block might be a suitable alternative to lumbar plexus block.
Asunto(s)
Músculos Abdominales/metabolismo , Bloqueo Nervioso/métodos , Músculos Abdominales/diagnóstico por imagen , Pared Abdominal/diagnóstico por imagen , Cadáver , Colorantes/farmacocinética , Medios de Contraste/farmacocinética , Disección , Humanos , Plexo Lumbosacro/diagnóstico por imagen , Plexo Lumbosacro/metabolismo , Azul de Metileno/farmacocinética , Tomografía Computarizada por Rayos X , Ultrasonografía Intervencional/métodosRESUMEN
Thoracic paravertebral blocks (TPVBs) have an extensive evidence base as part of a multimodal analgesic strategy for thoracic and breast surgery and have gained popularity with the advent of ultrasound guidance. However, this role is poorly defined in the context of abdominal surgery. We performed a systematic review of randomized controlled trials, to clarify the impact of TPVB on perioperative analgesic outcomes in adult abdominal surgery. We identified 20 published trials involving a total of 1044 patients that met inclusion criteria; however there was significant heterogeneity in terms of type of surgery, TPVB technique, comparator groups and study quality. Pain scores and opioid requirements in the early postoperative period were generally improved when compared with systemic analgesia, but there was insufficient evidence for any definitive conclusions regarding comparison with epidural analgesia or other peripheral block techniques, or the benefit of continuous TPVB techniques. The reported primary block failure rate was 2.8% and the incidence of complications was 1.2% (6/504); there were no instances of pneumothorax. TPVB therefore appears to be a promising analgesic technique for abdominal surgery in terms of efficacy and safety. But further well-designed and adequately powered studies are needed to confirm its utility, particularly with respect to other regional anaesthesia techniques.
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Abdomen/cirugía , Bloqueo Nervioso/métodos , Analgesia Epidural , Analgésicos Opioides/uso terapéutico , Humanos , Bloqueo Nervioso/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Vértebras TorácicasRESUMEN
Pre-procedural ultrasound imaging of the spine to identify the interspinous and interlaminar space has been shown to facilitate subsequent performance of lumbar neuraxial blockade. However, adequate visualization of the vertebral canal can be challenging for less-experienced operators, and particularly in subjects with difficult anatomy. In this case report, we describe a simplified technique of ultrasound-assisted neuraxial blockade that addresses these limitations and may thus be a useful fallback option. A pre-procedural scan is performed in which the main ultrasonographic landmarks to be identified are the neuraxial midline and the spinous processes, rather than the posterior and anterior complexes of the vertebral canal. Another key difference is the use of a paraspinous (or paramedian) needle approach rather than a midline approach that is advantageous where the interspinous spaces are narrowed by disease or suboptimal patient positioning. The anatomical basis and technical performance of this novel ultrasound-assisted paraspinous approach are presented in detail.
Asunto(s)
Anestesia Raquidea/métodos , Bloqueo Nervioso/métodos , Anestésicos Locales , Artroplastia de Reemplazo de Rodilla/métodos , Bupivacaína , Femenino , Humanos , Región Lumbosacra/diagnóstico por imagen , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Escoliosis/complicaciones , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Real-time ultrasound-guided neuraxial blockade remains a largely experimental technique. SonixGPS® is a new needle tracking system that displays needle tip position on the ultrasound screen. We investigated if this novel technology might aid performance of real-time ultrasound-guided spinal anesthesia. METHODS: Twenty patients with body mass index < 35 kg/m(2) undergoing elective total joint arthroplasty under spinal anesthesia were recruited. Patients with previous back surgery and spinal abnormalities were excluded. Following a pre-procedural ultrasound scan, a 17G proprietary needle-sensor assembly was inserted in-plane to the transducer in four patients and out-of-plane in 16 patients. In both approaches, the trajectory of insertion was adjusted in real-time until the needle tip lay just superficial to the ligamentum flavum-dura mater complex. At this point, a 25G 120 mm Whitacre spinal needle was inserted through the 17G SonixGPS® needle. Successful dural puncture was confirmed by backflow of cerebrospinal fluid from the spinal needle. RESULTS: An overall success rate of 14/20 (70%) was seen with two failures (50%) and four failures (25%) in the in-plane and out-of-plane groups respectively. Dural puncture was successful on the first skin puncture in 71% of patients and in a single needle pass in 57% of patients. The median total procedure time was 16.4 and 11.1 min in the in-plane and out-of-plane groups respectively. CONCLUSION: The SonixGPS® system simplifies real-time ultrasound-guided spinal anesthesia to a large extent, especially the out-of-plane approach. Nevertheless, it remains a complex multi-step procedure that requires time, specialized equipment, and a working knowledge of spinal sonoanatomy.
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Anestesia Raquidea/métodos , Ultrasonografía Intervencional/instrumentación , Anciano , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Índice de Masa Corporal , Sistemas de Computación , Procedimientos Quirúrgicos Electivos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/etiología , Satisfacción del Paciente , Punciones/efectos adversos , Punciones/métodos , Grabación de Cinta de VideoAsunto(s)
Analgesia , Bloqueo Nervioso , Fracturas de las Costillas , Analgésicos , Humanos , Estudios RetrospectivosRESUMEN
BACKGROUND: Thoracic epidural analgesia is considered the gold standard for pain relief in video-assisted thoracoscopic surgery. This neuraxial technique blocks pain sensation by injecting a local anesthetic agent in the epidural space near the spinal cord to block spinal nerve roots. Recently, the erector spinae plane block has been introduced as a practical alternative to the thoracic epidural. This interfascial regional anesthesia technique interrupts pain sensation by injecting a local anesthetic agent in between the muscular layers of the thoracic wall. Several case series and three RCTs described it as an effective pain management technique in video-assisted thoracoscopic surgery (Scimia et al., Reg Anesth Pain Med 42:537, 2017; Adhikary et al., Indian J Anaesth 62:75-8, 2018; Kim, A randomized controlled trial comparing continuous erector spinae plane block with thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery, n.d.; Yao et al., J Clin Anesth 63:109783, 2020; Ciftci et al., J Cardiothorac Vasc Anesth 34:444-9, 2020). The objective of this study is to test the hypothesis that a continuous erector spinae plane block incorporated into an opioid-based systemic multimodal analgesia regimen is non-inferior in terms of the quality of postoperative recovery compared to continuous thoracic epidural local anesthetic-opioid analgesia in patients undergoing elective unilateral video-assisted thoracoscopic surgery. METHODS: This is a prospective randomized open label non-inferiority trial. A total of 90 adult patients undergoing video-assisted thoracoscopic surgery will be randomized 1:1 to receive pain treatment with either (1) continuous erector spinae plane block plus intravenous patient-controlled analgesia with piritramide (study group) or (2) continuous thoracic epidural analgesia with a local anesthetic-opioid infusate (control group). All patients will receive additional systemic multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs. The primary endpoint is the quality of recovery as measured by the Quality of Recovery-15 score. Secondary endpoints are postoperative pain as Numerical Rating Score scores, length of hospital stay, failure of analgesic technique, postoperative morphine-equivalent consumption, itching, nausea and vomiting, total operative time, complications related to surgery, perioperative hypotension, complications related to pain treatment, duration of bladder catheterization, and time of first assisted mobilization > 20 m and of mobilization to sitting in a chair. DISCUSSION: This randomized controlled trial aims to confirm whether continuous erector spinae plane block plus patient-controlled opioid analgesia can equal the analgesic effect of a thoracic epidural local anesthetic-opioid infusion in patients undergoing video-assisted thoracoscopic surgery. TRIAL REGISTRATION: Netherlands Trial Register NL6433 . Registered on 1 March 2018. This trial was prospectively registered.
Asunto(s)
Analgesia Epidural , Bloqueo Nervioso , Adulto , Analgesia Epidural/efectos adversos , Analgésicos Opioides/efectos adversos , Humanos , Bloqueo Nervioso/efectos adversos , Países Bajos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Cirugía Torácica Asistida por Video/efectos adversosRESUMEN
Spinal anesthesia may be challenging in patients with poorly palpable surface landmarks or abnormal spinal anatomy. Pre-procedural ultrasound imaging of the lumbar spine can help by providing additional anatomical information, thus permitting a more accurate estimation of the appropriate needle insertion site and trajectory. However, actual needle insertion in the pre-puncture ultrasound-assisted technique remains a 'blind' procedure. We describe two patients with an abnormal spinal anatomy in whom ultrasound-assisted spinal anesthesia was unsuccessful. Successful dural puncture was subsequently achieved using a technique of real-time ultrasound-guided spinal anesthesia. This may be a useful option in patients in whom landmark-guided and ultrasound-assisted techniques have failed.
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Anestesia Raquidea/métodos , Vértebras Lumbares/anomalías , Ultrasonografía Intervencional/métodos , Anciano , Anciano de 80 o más Años , Anestesia Raquidea/instrumentación , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Duramadre/diagnóstico por imagen , Femenino , Humanos , Ligamento Amarillo/diagnóstico por imagen , Vértebras Lumbares/diagnóstico por imagen , Masculino , Agujas , Escoliosis/diagnóstico por imagen , Canal Medular/diagnóstico por imagen , Fusión Vertebral , TransductoresRESUMEN
Mouse mAb M38 was used in indirect immunofluorescence experiments to detect a stage-specific antigen on the surface of the first larval stage (L1) of the free-living nematode Caenorhabditis elegans, and to detect alterations in the apparent expression of this antigen in two distinct classes of C. elegans mutants. In previously described srf-2 and srf-3 mutants (Politz S. M., M. T. Philipp, M. Estevez, P.J. O'Brien, and K. J. Chin. 1990. Proc. Natl. Acad. Sci. USA. 87:2901-2905), the antigen is not detected on the surface of any stage. Conversely, in srf-(yj43) and other similar mutants, the antigen is expressed on the surface of the first through the fourth (L4) larval stages. To understand the molecular basis of these alterations, the antigen was characterized in gel immunoblotting experiments. After SDS-PAGE separation and transfer to nitrocellulose, M38 detected a protein antigen in extracts of wild-type L1 populations. The antigen was sensitive to digestion by Pronase and O-glycanase (endo-alpha-N-acetylgalactosaminidase), suggesting that it is an O-linked glycoprotein. This antigen was not detected in corresponding extracts of wild-type L4s or srf-2 or srf-3 L1s, but was detected in extracts of srf-(yj43) L4s. The antigen-defective phenotype of srf-3 was epistatic to the heterochronic mutant phenotype of srf-(yj43) in immunofluorescence tests of the srf-3 srf-(yj43) double mutant, suggesting that srf-(yj43) causes incorrect regulation of a pathway of antigen formation that requires wild-type srf-3 activity.