Extrafasicular and Intraperineural, but No Endoneural, Spread after Deliberate Intraneural Injections in a Cadaveric Study.

BACKGROUND: There is confusion regarding the spread of intraneurally injected local anesthetic agents during regional anesthesia. The aim of this research was to deliberately inject a marker that does not leave the neural compartment into which it is injected, and then to study the longitudinal and circumferential spread and possible pathways of intraneural spread. METHODS: After institutional review board approval, we intraneurally injected 20 and 5 ml of heparinized blood solution under ultrasound guidance into 12 sciatic nerves in the popliteal fossa and 10 median nerves, respectively, of eight fresh, unembalmed cadavers using standard 22-gauge "D" needles, mimicking the blocks in clinical conditions. Ultrasound evidence of nerve swelling confirmed intraneural injection. Samples of the nerves were then examined under light and scanning electron microscopy. RESULTS: Extrafascicular spread was observed in all the adipocyte-containing neural compartments of the 664 cross-section samples we examined, but intrafascicular spread was seen in only 6 cross-sections of two nerves. None of the epineurium, perineurium, or neural components were disrupted in any of the samples. Spread between the layers of the perineurium was a route of spread that included the perineurium surrounding the fascicles and the perineurium that formed incomplete septa in the fascicles. Similar to the endoneurium proper, subepineural compartments that did not contain any fat cells did not reveal any spread of heparinized blood solution cells. No "perineural" spaces were observed within the endoneurium. We also did not observe any true intrafascicular spread. CONCLUSIONS: After deliberate intraneural injection, longitudinal and circumferential extrafascicular spread occurred in all instances in the neural compartments that contained adipocytes, but not in the relatively solid endoneurium of the fascicles.

Modeling, Production, and Testing of an Echogenic Needle for Ultrasound-Guided Nerve Blocks.

We have designed, produced, and tested an echogenic needle based on a sawtooth pattern where the height of the tooth was 1.25 times the wavelength of the ultrasound transducer. A numeric solution to the time-independent wave equation (Helmholtz equation) was used to create a model of backscattering from a needle. A 21-gauge stainless steel prototype was manufactured and tested in a water bath. Backscattering from the needle was compared to theoretical predications from our model. Based on these results, an 18-gauge prototype needle was fabricated from stainless steel and tested in a pig cadaver. This needle was compared to a commercial 18-gauge echogenic needle (Pajunk Medical Systems, Tucker, GA) by measuring the brightness of the needle relative to the background of sonograms of a needle in a pig cadaver. The backscattering from the 21-gauge prototype needle reproduced the qualitative predictions of our model. At 30° and 45° of insonation, our prototype performed equivalently to the Pajunk needle. At 60°, our prototype was significantly brighter than the Pajunk needle (P = .017). In conclusion, we chose a model for the design of an echogenic needle and modeled it on the basis of a solution to the Helmholtz equation. A prototype needle was tested in a water bath and compared to the model prediction. After verification of our model, we designed an 18-gauge needle, which performed better than an existing echogenic needle (Pajunk) at 60° of insonation. Our needle will require further testing in human trials.

Different Approaches to Ultrasound-guided Thoracic Paravertebral Block: An Illustrated Review.

Given the fast development and increasing clinical relevance of ultrasound guidance for thoracic paravertebral blockade, this review article strives (1) to provide comprehensive information on thoracic paravertebral space anatomy, tailored to the needs of a regional anesthesia practitioner, (2) to interpret ultrasound images of the thoracic paravertebral space using cross-sectional anatomical images that are matched in location and plane, and (3) to briefly describe and discuss different ultrasound-guided approaches to thoracic paravertebral blockade. To illustrate the pertinent anatomy, high-resolution photographs of anatomical cross-sections are used. By using voxel anatomy, it is possible to visualize the needle pathway of different approaches in the same human specimen. This offers a unique presentation of this complex anatomical region and is inherently more realistic than anatomical drawings.

Novel approaches in pain management in cardiac surgery.

PURPOSE OF REVIEW: Open cardiac surgery may cause severe postoperative pain and the activation of a perioperative stress response. If not treated adequately, the patient may suffer increased morbidity, a longer hospital stay, and higher overall costs. This article reviews the literature regarding various modalities for management of postoperative pain after cardiac surgery. RECENT FINDINGS: Paravertebral block of the spinal nerve roots provides similar analgesia to thoracic epidural without the risk of hypotension or epidural hematoma. Continuous α-2 agonist infusion reduces opioid requirements in the immediate postoperative period and may convey a morbidity and mortality benefit in cardiac surgery patients that persists for 12 months. Antiepileptics may significantly decrease opioid requirements and improve pain scores. Finally, complementary and alternative practices such as acupuncture, music, and behavioral exercises both pre and postoperatively may improve acute pain and lessen conversion to chronic pain. SUMMARY: Although published data remain limited, recent evidence indicates that patients may benefit from the addition of a variety of novel pain-management strategies currently under investigation. Selection of a multimodal approach to perioperative pain management is advocated, including selective application of regional analgesia, non-narcotic medications, and complimentary alternative options to improve patient comfort and overall outcome.

The influence of patient position on ultrasound examination of the sciatic nerve in the popliteal fossa: A cross-sectional study.

Introduction/Purpose: Ultrasound-guided popliteal fossa sciatic nerve (PFSN) blocks are performed with patients in the supine, lateral or prone position. No known studies compare the quality of images obtained from each approach. This study examines the quality of supine and prone PFSN ultrasound images. Methods: Thirty-eight adult volunteers were sorted into two groups. Five regional anaesthesiologists performed ultrasound examinations of the PFSN on volunteers in supine and prone positions. Popliteal fossa sciatic nerve image quality was analysed with grayscale techniques and peer evaluation. Popliteal fossa sciatic nerve depth, distance from the popliteal crease and time until optimal imaging were recorded. Results: The grayscale ratio of the PFSN vs. the background was 1.83 (supine) and 1.75 (prone) (P = 0.034). Similarly, the grayscale ratio of the PFSN vs. the immediately adjacent area was 1.65 (supine) and 1.55 (prone) (P = 0.004). Mean depth of the PFSN was 1.6 cm (supine) and 1.7 cm (prone) (P = 0.009). Average distance from the popliteal crease to the PFSN was 5.9 cm (supine) and 6.6 cm (prone) (P = 0.02). Mean time to acquire optimal imaging was 36 s (supine) and 47 s (prone) (P = 0.002). Observers preferred supine positioning 53.8%, prone positioning 22.5% and no preference 23.7% of the time. Observers with strong preferences preferred supine imaging in 70.9% of cases. Conclusions: Supine ultrasound examination offered quicker identification of the PFSN, in a more superficial location, closer to the popliteal crease and with enhanced contrast to surrounding tissue, correlating with observer preferences for supine positioning. These results may influence ultrasound-guided PFSN block success rates, especially in difficult-to-image patients.

Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block.

BACKGROUND: A stimulation current of no more than 0.5 mA is regarded as safe in avoiding nerve injury and delivering adequate stimulus to provoke a motor response. However, there is no consistent level of stimulating threshold that reliably indicates intraneural placement of the needle. The authors determined the minimally required stimulation threshold to elicit a motor response outside and inside the most superficial part of the brachial plexus during high-resolution, ultrasound-guided, supraclavicular block. METHODS: After institutional review board approval, ultrasound-guided, supraclavicular block was performed on 55 patients. Patients with neurologic dysfunction were excluded. Criteria for extraneural and intraneural stimulation were defined and assessed by independent experts. To determine success rate and any residual neurologic deficit, qualitative sensory and motor examinations were performed before and after block placement. At 6 month follow-up, the patients were examined for any neurologic deficit. RESULTS: Thirty-nine patients met all set stimulation criteria. Median +/- SD (interquartile range) minimum stimulation threshold outside was 0.60 +/- 0.37 mA (0.40, 1.0) and inside 0.30 +/- 0.19 mA (0.20, 0.40). The difference of 0.30 mA was statistically significant (P < 0.0001). Stimulation currents of 0.2 mA or less were not observed outside the trunk in any patient. Significantly higher thresholds were observed in diabetic patients. Success rate was 100% after 20 min. Thirty-four patients had normal sensory and motor examination at 6 months. Five patients were lost to follow-up. CONCLUSION: Within the limitations of this study and the use of ultrasound, a stimulation current of 0.2 mA or less is reliable to detect intraneural placement of the needle. Furthermore, stimulation currents of more than 0.2 and no more than 0.5 mA could not rule out intraneural position.

Ultrasound-guided paravertebral block using an intercostal approach.

We describe an ultrasound-guided technique of continuous bilateral paravertebral block using an intercostal approach in 12 patients undergoing elective abdominal surgery. Postoperatively, each of the patient's paravertebral catheters was bolused with 10 mL lidocaine (15 mg/mL), and each of the patient's catheters was infused with 0.2% ropivacaine at 10 mL/h. Using a pinprick test, the median number of dermatomes blocked after the initial bolus was 5 (interquartile range, 4-6), and 23 of 24 catheters produced a local anesthetic block. The median verbal pain score on postoperative day 1 was 5.5 (interquartile range, 3.5-6), and median dose of IV hydromorphone consumed during the first 24 h after surgery was 1.9 mg (interquartile range, 0.7-5.05). All catheters were removed within 72 h after surgery.

Quantitative architecture of the brachial plexus and surrounding compartments, and their possible significance for plexus blocks.

BACKGROUND: Nerve injury after regional anesthesia of the brachial plexus (BP) is a relatively rare and feared complication that is partly attributed to intraneural injection. However, recent studies have shown that intraneural injection does not invariably cause neural injury, which may be related to the architecture within the epineurium. A quantitative study of the neural components and the compartment outside BP was made. METHODS: From four frozen shoulders, high-resolution images of sagittal cross-sections with an interval of 0.078 mm were obtained using a cryomicrotome to maintain a relatively undisturbed anatomy. From this data set, cross-sections perpendicular to the axis of the BP were reconstructed in the interscalene, supraclavicular, midinfraclavicular, and subcoracoid regions. Surface areas of both intraepineurial and connective tissue compartments outside the BP were delineated and measured. RESULTS: The nonneural tissue (stroma and connective tissue) inside and outside the BP increased from proximal to distal, being significant between interscalene/supraclavicular and midinfraclavicular/subcoracoid regions (P < 0.001 for tissue inside BP, P < 0.02 for tissue outside BP). The median amount of neural tissue remained approximately the same in the four measured regions (41.1 +/- 6.3 mm; range, 30-60 mm). The ratio of neural to nonneural tissue inside the epineurium increased from 1:1 in the interscalene/supraclavicular to 1:2 in the midinfraclavicular/subcoracoid regions. CONCLUSION: Marked differences in neural architecture and size of surrounding adipose tissue compartments are demonstrated between proximal and distal parts of the brachial plexus. These differences may explain why some injections within the epineurium do not result in neural injury and affect onset times of BP blocks.

Ultrasound-guided infraclavicular block in an anticoagulated and anesthetized patient.

The author describes the use of ultrasound to facilitate a continuous infraclavicular brachial plexus block in a patient who had been anticoagulated with 5000 U of heparin. The procedure was done 2 h after the patient was anticoagulated, and his activated clotting time was 203 s. The patient had vascular checks with a laser Doppler monitor every hour and neurological checks every 12 h.

In vitro evaluation of a micro-Doppler catheter for detection and aspiration of venous air emboli.

BACKGROUND: Venous air embolism (VAE) is a potentially fatal complication of surgery when open veins at a surgical site are exposed to ambient air pressure which exceeds the pressure in the venous system. Common techniques of detecting VAE are precordial Doppler monitoring and transesophogeal echocardiography. Precordial Doppler monitoring has poor accuracy and transesophogeal echocardiography is expensive and user-intensive. In both methods, a separate catheter must be inserted into the vena cava so that an embolus may be aspirated if it is detected. METHODS: We created a micro-Doppler assembly using two ceramic transducers fitted over a 5.8F multiorifice central venous catheter. This micro-Doppler catheter (MDC) was tested in vitro using a static tank and an artificial vena cava (AVC). The MDC was also tested for acoustic pressure and current leakage in the static tank and for heat generation and cavitation in the AVC. RESULTS: The MDC was able to detect bubbles more than 2 mm in diameter with 100% accuracy. A blinded observer was able to identify the onset of vapor lock in 10 of 10 trials. The same observer was able to terminate vapor lock in 10 of 10 trials. The acoustic pressures measured were <1.8 MPa. There was no increase in temperature in the AVC over 24 h and there was no evidence of cavitation in the AVC over 4 h. CONCLUSION: We have created a MDC that can detect air emboli and relieve vapor lock in a simulated vena cava and atrium. This catheter could be placed percutaneously in the vena cava. Based on the measurements of acoustic pressure, temperature in the AVC and lack of cavitation in the AVC, the device appears to be safe for use in humans. More studies are required to determine if the catheter could be used to detect and aspirate VAE during surgeries where VAE is likely, such as sitting craniotomy.

Design and Production of an Articulating Needle Guide for Ultrasound-Guided Needle Block Manufactured With a Three-Dimensional Printer: Technical Communication.

Needle guides may allow the practitioner to align the needle with the probe when ultrasound-guided nerve block is performed. The author's goal was to design and fabricate an inexpensive ($1.90), disposable, needle guide that could articulate over a range from 85 degrees to 0 degrees with a three-dimension printer. Three-dimensional representations of an L50, L25, and C 60 ultrasound probe (Sono Site, Bothell, WA) were created using a laser scanner. Computer-aided design software (Solid Works, Waltham, MA) was used to design a needle bracket and needle guide to attach to these probes. A three-dimensional printer was used to fabricate the needle bracket and guide with acrylonitrile polybutadiene polystyrene. An echogenic needle was held in plane with the needle guide. The author performed a supraclavicular block in a morbidly obese patient. The needle was easily visualized. Similar guides that are commercially available cost as much as $400. A knowledge of computer-aided design is necessary for this work.

The bifid axillary artery.

The anesthetic of a patient who presented for vascular access under axillary block is described. After physical examination and ultrasound study, the patient was found to have a bifid axillary artery. Because of neurologic anomalies associated with this vascular variation, an interscalene block was chosen for the procedure. The clinical implications of a bifid axillary artery when an axillary block is contemplated are discussed.

Airway obstruction mimicking superior vena cava syndrome in a patient undergoing dialysis graft revision after ultrasound-guided supraclavicular nerve block.

A 25-year-old man presented for revision of a dialysis fistula in his left upper arm. An ultrasound-guided left supraclavicular block was performed, and 4 hours later during wound closure, the patient developed intermittent airway obstruction accompanied by edema of the face and upper airway. Superior vena cava syndrome was suspected, and awake fiberoptic tracheal intubation was performed. Partial obstruction of the left brachiocephalic vein and right internal jugular vein were identified while the patient was in the radiology suite. Sympathetic block and increased venous return from the left arm likely contributed to his airway obstruction that mimicked superior vena cava syndrome.

Coherence-gated Doppler: a fiber sensor for precise localization of blood flow.

Miniature optical sensors that can detect blood vessels in front of advancing instruments will significantly benefit many interventional procedures. Towards this end, we developed a thin and flexible coherence-gated Doppler (CGD) fiber probe (O.D. = 0.125 mm) that can be integrated with minimally-invasive tools to provide real-time audio feedback of blood flow at precise locations in front of the probe. Coherence-gated Doppler (CGD) is a hybrid technology with features of laser Doppler flowmetry (LDF) and Doppler optical coherence tomography (DOCT). Because of its confocal optical design and coherence-gating capabilities, CGD provides higher spatial resolution than LDF. And compared to DOCT imaging systems, CGD is simpler and less costly to produce. In vivo studies of rat femoral vessels using CGD demonstrate its ability to distinguish between artery, vein and bulk movement of the surrounding soft tissue. Finally, by placing the CGD probe inside a 30-gauge needle and advancing it into the brain of an anesthetized sheep, we demonstrate that it is capable of detecting vessels in front of advancing probes during simulated stereotactic neurosurgical procedures. Using simultaneous ultrasound (US) monitoring from the surface of the brain we show that CGD can detect at-risk blood vessels up to 3 mm in front of the advancing probe. The improved spatial resolution afforded by coherence gating combined with the simplicity, minute size and robustness of the CGD probe suggest it may benefit many minimally invasive procedures and enable it to be embedded into a variety of surgical instruments.

Brachial plexus root injection in a human cadaver model: injectate distribution and effects on the neuraxis.

BACKGROUND: The potential for injection into the brachial plexus root at cervical levels must be considered during interscalene block or chronic pain interventions in the neck, but this phenomenon has not been well studied. In this investigation, we performed injections into the brachial plexus roots of unembalmed cadavers, with real-time ultrasound guidance, to evaluate the proximal and distal spread of the injected fluids, the potential of the injectate to reach the neuraxis, and whether the injectate could migrate into the actual substance of the spinal cord itself. METHODS: A solution of particulate dye mixed with local anesthetic was injected into 8 brachial plexus roots at a lower cervical level, in unembalmed cadaver specimens, utilizing an automated pump and pressure monitor. Two injections were made adjacent to nerve roots as controls. The specimens were then dissected, and gross and microscopic analysis utilized to determine the distribution of the dye and the structures affected. RESULTS: The mean peak pressure achieved during plexus root injections was 48.9 psi. After injections into the plexus root, dye was evident within the neural tissue at the level of injection and spread primarily distally in the plexus. In 1 of 8 injections into the brachial plexus root, the dye in the injectate spread proximally into the spinal canal, but in none of the injections was the spinal cord affected by the dye. CONCLUSIONS: Injection directly into the neural tissue of a brachial plexus root in a cadaver model produced high pressures suggestive of intrafascicular injection and widespread flow of the injectate through the distal brachial plexus. However, proximal movement of the dye-containing injectate was more restricted, with only 1 of the injections leading to epidural spread and no apparent effects on the spinal cord.

Subepineurial injection in ultrasound-guided interscalene needle tip placement.

INTRODUCTION: The neural elements of the brachial plexus between the anterior and middle scalene muscles are readily visible by ultrasound. However, the epineurium of these nerve structures is difficult to discern on ultrasound imaging because of the proximity of the scalene muscles to the nerve elements, and this may lead to unintentional subepineurial injection (SEI). To evaluate whether typical needle tip placement under ultrasound guidance results in SEI, as opposed to extraneural injection, we undertook this cadaver study. MATERIALS AND METHODS: Six nonpreserved cadavers served as subjects for 10 injections. After imaging revealed the hypoechoic fascicles of the brachial plexus at the interscalene level, the tip of a 22-gauge, 5-cm short-bevel needle was inserted into a position adjacent to one of the fascicles by ultrasound guidance. At this point, 0.1 to 0.2 mL of india ink solution was injected. The brachial plexus at this level was then dissected and removed. The nerve elements discolored by the ink were removed, fixed, and stained for histologic analysis and were then examined for evidence of subepineurial ink deposition. Four nerve segments, which were unaffected by the injected ink, served as controls. These were subjected to topical india ink application for a 60-min period and were then washed, fixed, and stained for histologic analysis. RESULTS: In all 10 interscalene sites, ultrasonography revealed multiple hypoechoic nodules that could be traced proximally to the spine, as in live subjects. On gross analysis after dissection, the superficial nerve elements of the brachial plexus appeared to be stained by the ink. On histologic examination, 5 of 10 nerve specimens revealed ink within the epineurium (subepineurial), whereas in the other 5, it had not penetrated this barrier. The india ink did not penetrate the perineurium in any of the specimens. Among control specimens, none had evidence of subepineurial ink. CONCLUSIONS: In a cadaver model of needle tip placement for ultrasound-guided interscalene block, we found that SEI occurred more frequently than expected.