Combination Preemptive Peripheral Nerve Block in Limb Surgery. A Prospective Study.

Background and objectives: Patients often suffer from moderate to severe pain during the early recovery period in orthopedic surgery. We investigated the impact of a single-shot preoperative peripheral nerve block (PNB) on post-anesthesia recovery parameters and interleukin (IL)-6 level during limb surgery. Materials and Methods: A prospective randomized controlled study was conducted, and patients scheduled for limb surgery were recruited. Sixty patients were randomly assigned to either the PNB group or control group, who received morphine as a primary analgesic. The peak verbal numeric rating scale (NRS) score in the post-anesthesia care unit (PACU) was evaluated as a primary outcome. We also recorded rescue analgesics requirement and wake-up time from anesthesia in the PACU. In addition, the change of plasma IL-6 level after incision was measured. Results: Fifty-two patients completed the study, 27 and 25 cases in the PNB and control group, respectively. Preemptive PNB significantly reduced peak NRS score in the PACU compared to control group. Lower rescue analgesics requirement and rapid wake-up from anesthesia were also noted in PNB group. The IL-6 concentration increased less in the PNB group at 2 h after incision. Conclusions: Preemptive PNB attenuates IL-6 expression 2 h after incision and improves pain management in the PACU. PNB was considered as an essential part of pain management in limb surgery.

Great Auricular Neuralgia: Case Series.

BACKGROUND/OBJECTIVE: The great auricular nerve (GAN) arises from C2-C3 and provides innervation over the skin in the pre-auricular region, jaw angle, posteroinferior pinna, and mastoid. Although damage to the GAN has been reported following trauma or procedures nearby this nerve course, neuralgia of this nerve is uncommon with knowledge based on a handful of case reports in literature. The objective of this study is to describe the presentation, treatment, and outcome of 13 cases of GAN neuralgia. METHODS: Case series. Retrospecive review of charts from 1994 to 2018 with diagnoses: "auricular neuralgia," "auricular neuritis," or "auricular neuropathy." We included subjects with neuralgic pain within the distribution of the GAN, and excluded patients with atypical facial pain, GAN neuropathy, or unclear etiology. RESULTS: Of 79 charts, 13 patients met criteria (age at onset 11-59; 11 women, 2 men). Pain was most often described as paroxysmal stabbing provoked by: turning the head (n = 7), touching the neck (n = 5), neck position during sleep (n = 2), jaw movement (n = 2), and other (n = 2). Seven patients received GAN blocks: all noted dramatic improvement in pain, including 3 who continued to receive serial blocks at our institution successfully for the next 2 to 5 years. Two patients successfully transitioned from GAN blocks to GAN stimulators. One patient with GAN lymphoma had resolution of pain following GAN resection. CONCLUSION: GAN neuralgia should be considered in the differential for periauricular pain. GAN blocks or stimulators may be helpful for pain management.

Treatment of chronic osteoarthritic hip pain with phenol neurolysis of the obturator nerve Quadfen1 / Tratamento da dor crônica na osteoartrite do quadril com neurólise do nervo obturador com fenol Quadfen1

The conservative treatment of osteoarthritis (OA) of the hip is essentially symptomatic, seeking to relieve pain and optimize function. Despite presenting great clinical effect, hip arthroplasty may have restrictions, and in these situations, the neurolytic blockade of the anterior branch of the obturator nerve can be a therapeutic alternative, since it stops the afferent pain from the hip joint. Objective: To describe the results of treating patients with severe OA of the hip by applying phenol to the obturator nerve. Method: Twelve consecutive patients with OA of the hip, refractory to conservative treatment, were recruited to have the obturator nerve localized through electrostimulation and blocked with phenol. They were evaluated in terms of pain intensity via the visual analogue scale (VAS), pressure dolorimetry in the medial and lateral gluteus medius, gluteus minimus, and piriformis, and quality of life by the Harris Hip Score (HHS) at baseline (BL) after 1 (M1), 2 (M2), and 6 months (M6). Results: The patients were between 30 and 72 years old with an avarege of 47.5 ± 1.7 years old, 5 of them were women. Three patients were excluded for not being able to come for follow up evaluations. VAS values vaieded from 8.2 ±.0.9 at BL to 6.6 ± 1.7 at M1, 6.5 ± 1.7 at M2, and 7.3 ± 1 in M6 (p=0.0094). As to the HHS, the values were BL:33.27 ± 2.9; M1:39.2 ± 6.4; M2:40.2 ± 8.1, and M6: 38.8 ± 9.7 in the final evaluation (p=0,040). For dolorimetry, non significant variation was BL: 11±5.7, M1: 7.9±2.2; M2: 10.9±5.6; M6: 8.1 ± 1.6 (p 0.69). Conclusion: The application of phenol to the anterior branch of the obturator nerve can be an alternative in the treatment of severe OA of the hip in patients with restrictions to Total Hip Replacement (THR), since it reduces pain and improves quality of life.

O tratamento conservador da osteoartrite (OA) do quadril é essencialmente sintomático, visando alívio da dor e otimização da funcionalidade. Apesar de apresentar grande efeito clínico, a artroplastia quadril pode ter restrições, nestas situações o bloqueio do ramo anterior do nervo obturador (RAO) pode ser uma alternativa terapêutica, uma vez que interrompe a aferência dolorosa da articulação do quadril. Objetivo: Descrever os resultados do tratamento de pacientes com OA grave do quadril por meio da aplicação de fenol no nervo obturatório. Método: Nove pacientes com OA de quadril resistente ao tratamento conservador que se apresentaram consecutivamente ao nosso serviço foram submetidos à aplicação de fenol no nervo obturatório com localização por meio de eletroestimulação e avaliados quanto a intensidade de dor pela escala visual analógica (EVA), dolorimetria de pressão e qualidade de vida pelo Haris Hip Score (HHS) após 01, 02 e 06 meses. Resultados: Foram selecionados 12 pacientes que preenchiam os critérios de inclusão e exclusão, destes, 3 foram excluídos após não conseguirem mais comparecer para as avaliações. Os valores médios de EVA variaram de 8,2 ±.0,9 na medida basal para 6,6 ± 1,7 ao final de um mês, 6,5 ± 1,7 ao final de dois meses e 7,3 ± 1 com 06 meses (p=0,0094). Quanto ao HHS, os valores foram 33,27 ± 2,9; 39,2 ± 6,4; 40,2 ± 8,1 e 38,8 ± 9,7, na avaliação final. A última variável analisada foi a Dolorimetria, onde foi realizada a média entre os valores atingidos pela avaliação com o dolorímetro no glúteo médio medial, glúteo médio lateral, glúteo mínimo e piriforme. Na avaliação inicial média de 11±5,7, 7,9±2,2 no final do primeiro mês, 10,9±5,6 no segundo e no 6º mês 8,1±1,6. Ao aplicarmos o teste ANOVA, não foi observado diferença estatística (p 0,69). Conclusão: A aplicação de Fenol em RAO pode ser uma alternativa no tratamento da OA de quadril grave em pacientes com restrições à realização de ATQ, pois implica em redução da dor e melhora da qualidade de vida.

Challenges associated with nerve conduction block using kilohertz electrical stimulation.

Neuromodulation therapies, which electrically stimulate parts of the nervous system, have traditionally attempted to activate neurons or axons to restore function or alleviate disease symptoms. In stark contrast to this approach is inhibiting neural activity to relieve disease symptoms and/or restore homeostasis. One potential approach is kilohertz electrical stimulation (KES) of peripheral nerves-which enables a rapid, reversible, and localized block of conduction. This review highlights the existing scientific and clinical utility of KES and discusses the technical and physiological challenges that must be addressed for successful translation of KES nerve conduction block therapies.

A Vibration Device to Control Injection Discomfort.

Pain from local anesthesia injections can be reduced by distraction and counter-stimulation techniques. This study investigated the DentalVibe® Injection Comfort System (third-generation, DV3), developed to lessen anesthesia pain through pulsed vibration, a form of counter-stimulation. The aim of the study was to evaluate both the efficacy of DV3 in reducing pain and discomfort from intraoral long buccal (LB) and inferior alveolar nerve (IAN) injections and the time needed to achieve complete anesthesia during an IAN block. The study enrolled 60 subjects, 30 men and 30 women, aged 21 to 32 years, who rated both injection pain on a visual analog scale and discomfort, unpleasantness, and difficulty in enduring the injection on a modified symptom severity index. Each subject received bilateral LB injections and an IAN block. Using block design, the third-generation DV (DV3) was randomly assigned to either the first or second LB injection and to 30 subjects on their third injection, the IAN block. No topical anesthesia was applied. Subjects receiving DV3 reported significantly less pain, discomfort, unpleasantness, and difficulty in enduring LB and IAN injections (P < .05), regardless of whether DV3 was used on the first or second LB injection. Time to complete anesthesia was not significantly different (P > .05) when DV3 was used on IAN block injections. The DV3 significantly (P < .02) reduced pain/discomfort from anesthetic injections in this pilot study, in which many subjects were either dental or medical students familiar with performing and enduring injections. More studies are warranted on layperson populations.

[Clinical evaluation of in-plane ultrasound-guided thoracic paravertebral block using laterally intercostal approach].

OBJECTIVE: To evaluate the feasibility and success rate of in-plane ultrasound-guided paravertebral block using laterally intercostal approach. METHODS: In the study, 27 patients undergoing elective thoracic surgery were selected to do paravertebral block preoperatively. The fifth intercostal space was scanned by ultrasound probe which was placed along the long axis of the rib and 8 cm lateral to the midline of the spine. The needle was advanced in increments aiming at the space between the internal and innermost intercostal muscles. Once the space between the muscles was achieved, 20 mL of 0.5% (mass fraction) ropivacaine was injected and a catheter was inserted. Whether the tip of catheter was in right place was evaluated by ultrasound image. The block dermatomes of cold sensation were recorded 10, 20 and 30 min after the bolus drug was given. Then 0.2% ropivacaine was infused with 6 mL/h via the catheter by an analgesia pump postoperatively. The block dermatomes of cold sensation and pain score were recorded 1, 6, 24 and 48 h postoperatively. RESULTS: The first attempt success rate of catheteration was 81.48% (22/27); the tips of catheter were proved in right places after the second or third attempt in 5 patients. The median numbers of the block dermatomes 10, 20 and 30 min after the bolus drug was given were 2, 3, 4; the median numbers of block dermatomes were 5, 5, 5, 4, and of pain score were 1, 1, 2, 2 at 1, 6, 24, 48 h postoperatively; no case of bilateral block, pneumothorax or vessel puncture occurred. CONCLUSION: Thoracic paravertebral block using laterally intercostal approach is feasible, which has high success rate of block and low rate of complications.

Ultrasensitive Phototriggered Local Anesthesia.

An injectable local anesthetic producing repeatable on-demand nerve block would be desirable for pain management. Here we present a phototriggerable device to achieve repeatable and adjustable on-demand local anesthesia in superficial or deep tissues, consisting of gold nanorods attached to low temperature sensitive liposomes (LTSL). The particles were loaded with tetrodotoxin and dexmedetomidine. Near-infrared light (NIR, 808 nm, continuous wave) could heat gold nanorods at low fluence (short duration and low irradiance), leading to rapid release of payload. In vivo, 1-2 min of irradiation at ≤272 mW/cm2 produced repeatable and adjustable on-demand infiltration anesthesia or sciatic nerve blockade with minimal toxicity. The nerve block intensity and duration correlated with the irradiance and duration of the applied light.

Continuous Direct Current Nerve Block Using Multi Contact High Capacitance Electrodes.

Charge-balanced direct current (CBDC) nerve block can be used to block nerve conduction in peripheral nerves. Previous work demonstrated that the CBDC waveform could be used to achieve a 10% duty cycle of block to non-block repeatedly for at least two hours. We demonstrate that the duty cycle of this approach can be significantly increased by utilizing multiple electrode contacts and cycling the CBDC waveform between each contact in a "carousel" configuration. Using this approach, we demonstrated in an acute rat sciatic nerve preparation, that a 30% duty cycle complete block can be achieved with two contacts; and a 100% duty cycle block (>95% complete block) can be achieved with four contacts. This latter configuration utilized a 4-s block plateau, with 3 s between successive plateaus at each contact and a recharge phase amplitude that was 34% of the block amplitude. Further optimization of the carousel approach can be achieved to improve block effectiveness and minimize total electrode length. This approach may have significant clinical use in cases where a partial or complete block of peripheral nerve activity is required. In one example case, we achieved continuous block for 22 min without degradation of nerve conduction. Future study will be required to further optimize this technique and to demonstrate safety for chronic human use.

Holistic ultrasound in trauma: An update.

Holistic ultrasound is a total body examination using an ultrasound device aiming to achieve immediate patient care and decision making. In the setting of trauma, it is one of the most fundamental components of care of the injured patients. Ground-breaking imaging software allows physicians to examine various organs thoroughly, recognize imaging signs early, and potentially foresee the onset or the possible outcome of certain types of injuries. Holistic ultrasound can be performed on a routine basis at the bedside of the patients, at admission and during the perioperative period. Trauma care physicians should be aware of the diagnostic and guidance benefits of ultrasound and should receive appropriate training for the optimal management of their patients. In this paper, the findings of holistic ultrasound in trauma patients are presented, with emphasis on the lungs, heart, cerebral circulation, abdomen, and airway. Additionally, the benefits of ultrasound imaging in interventional anaesthesia techniques such as ultrasound-guided peripheral nerve blocks and central vein catheterization are described.

Continuous Adductor Canal Blocks: Does Varying Local Anesthetic Delivery Method (Automatic Repeated Bolus Doses Versus Continuous Basal Infusion) Influence Cutaneous Analgesia and Quadriceps Femoris Strength? A Randomized, Double-Masked, Controlled, Split-Body Volunteer Study.

BACKGROUND: It remains unknown whether continuous or scheduled intermittent bolus local anesthetic administration is preferable for adductor canal perineural catheters. Therefore, we tested the hypothesis that scheduled bolus administration is superior or noninferior to a continuous infusion on cutaneous knee sensation in volunteers. METHODS: Bilateral adductor canal catheters were inserted in 24 volunteers followed by ropivacaine 0.2% administration for 8 hours. One limb of each subject was assigned randomly to a continuous infusion (8 mL/h) or automated hourly boluses (8 mL/bolus), with the alternate treatment in the contralateral limb. The primary end point was the tolerance to electrical current applied through cutaneous electrodes in the distribution of the anterior branch of the medial femoral cutaneous nerve after 8 hours (noninferiority delta: -10 mA). Secondary end points included tolerance of electrical current and quadriceps femoris maximum voluntary isometric contraction strength at baseline, hourly for 14 hours, and again after 22 hours. RESULTS: The 2 administration techniques provided equivalent cutaneous analgesia at 8 hours because noninferiority was found in both directions, with estimated difference on tolerance to cutaneous current of -0.6 mA (95% confidence interval, -5.4 to 4.3). Equivalence also was found on all but 2 secondary time points. CONCLUSIONS: No evidence was found to support the hypothesis that changing the local anesthetic administration technique (continuous basal versus hourly bolus) when using an adductor canal perineural catheter at 8 mL/h decreases cutaneous sensation in the distribution of the anterior branch of the medial femoral cutaneous nerve.

Detection of intraneural needle-placement with multiple frequency bioimpedance monitoring: a novel method.

Electrical impedance measurements have been used to detect intraneural needle placement, but there is still a lack of precision with this method. The purpose of the study was to develop a method for the discrimination of nerve tissue from other tissue types based on multiple frequency impedance measurements. Impedance measurements with 25 different frequencies between 1.26 and 398 kHz were obtained in eight pigs while placing the tip of a stimulation needle within the sciatic nerve and in other tissues. Various impedance variables and measurement frequencies were tested for tissue discrimination. Best tissue discrimination was obtained by using three different impedance parameters with optimal measurement frequencies: Modulus (126 kHz), Phase angle (40 kHz) and the Delta of the phase angle (between 126 and 158 kHz). These variables were combined in a Compound variable C. The area under the curve in a receiver operating characteristic was consecutively increased for the Modulus (78 %), Phase angle (86 %), Delta of the phase angle (94 %), and the Compound variable C (97 %), indicating highest specificity and sensitivity for C. An algorithm based on C was implemented in a real-time feasibility test and used in an additional test animal to demonstrate our new method. Discrimination between nerve tissue and other tissue types was improved by combining several impedance variables at multiple measurement frequencies.

New perineal injection technique for pudendal nerve infiltration in diagnostic and therapeutic procedures.

PURPOSE: Pudendal nerve injection is used as a diagnostic procedure in the vulvar region and for therapeutic purposes, such as in vulvodynia. Here, we provide a new, easy-to-perform perineal injection technique. PATIENTS AND METHODS: We analyzed 105 perineal injections into the pudendal nerve with a local anesthetic (LA), procaine in 20 patients. A 0.4 × 40 mm needle was handled using a stop-and-go technique while monitoring the patient's discomfort. The needle was placed 1-2 cm laterally to the dorsal introitus. After aspiration, a small amount of LA was applied. After subcutaneous anesthesia, the needle was further advanced step-by-step. Thus, 5 ml could be applied with little discomfort to the patient. Anesthesia in the pudendal target region was the primary endpoint of our analysis. RESULTS: In 93 of 105 injections (88.6 %), complete perineal anesthesia was achieved with a single injection. 12 injections were repeated. These injections were excluded from the analysis. Severity of injection pain, on visual analog scale (VAS) from 0 to 100, was 26.8 (95 % CI 7.2-46.4). Age (ß = 0.33, p < 0.01) and the number of previous injections (ß = 0.35, p < 0.01) inversely correlated with injection pain. Injection pain and anesthesia were not affected by BMI, the number and the side of previous injections, or order of injection. A reversible vasovagal reaction was common, but no serious adverse effects occurred. CONCLUSION: Perineal pudendal injection is an effective and safe technique for anesthesia in diagnostic (vulva biopsy) and therapeutic indications (pudendal neuralgia), and regional anesthesia in perinatal settings.

Nail surgery: best way to obtain effective anesthesia.

Nail procedures require an effective and reliable approach to anesthesia of the distal digit. Several techniques have been described in the literature. Herein, the relevant anatomy of the nail unit, pain pathways, anesthetic options, and several injection approaches to achieve complete anesthesia are reviewed. Also considered are the potential pitfalls and complications and their management. Ultimately, the physician's approach must be individualized to the patient, procedure, and setting.

Effect of nerve localization using a pen device on the success of axillary brachial plexus block.

OBJECTIVE: The effectiveness of axillary brachial plexus block (ABPB) performed using peripheral nerve stimulation (PNS) alone was compared with PNS preceded by nerve localization using a pen device, enabling nerve mapping without puncturing the skin. METHODS: Patients undergoing unilateral hand or forearm surgery suitable for ABPB were randomly assigned to receive either PNS alone (pen - group) or PNS preceded by nerve localization using a pen device (pen + group). Parameters related to the block procedure and patient comfort were assessed. RESULTS: Thirty patients were included in each group. The block performance time was longer in the pen + group than the pen - group despite a reduced number of needle insertions. The complete block rate was higher and intraoperative analgesic usage lower in the pen + group compared with the pen - group. Patient satisfaction and complication rates were similar in the two groups. CONCLUSION: The pen device seems to be a helpful addition to PNS for ABPB, with improved results in terms of block success and patient comfort, but further studies are needed to confirm these findings.

Análisis de los factores de intubación difícil en cirugía bariátrica. Influencia en la elección del bloqueante neuromuscular de la disponibilidad de sugammadex / Analysis of difficult intubation factors in bariatric surgery. Influence of the choice of neuromuscular blocker on the availability of sugammadex

Objetivos. Determinar la incidencia de dificultad de intubación traqueal (DIT) en pacientes obesos operados de cirugía bariátrica y valorar los factores predictivos. El objetivo secundario fue determinar los factores que influyeron en la elección del bloqueante neuromuscular (succinilcolina o rocuronio). Métodos. Estudio observacional, prospectivo en pacientes consecutivos de cirugía bariátrica. Se efectuó la intubación traqueal mediante laringoscopia directa con un tubo traqueal con fiador. Se consideró DIT cuando se observó un grado en la clasificación de Cormack-Lehane III - IV o fue necesario aplicar el algoritmo para DIT (laringoscopia con guía Frova y, en caso de no poder intubar, videolaringoscopio Airtraq). Si con estas medidas no era posible la intubación traqueal, se administró sugammadex en aquellos pacientes con rocuronio y posteriormente se realizó la intubación traqueal con anestesia local y fibroscopio. Resultados. Se incluyó a a 166 pacientes. En un caso se realizó la intubación con fibroscopio. De los 165 pacientes restantes, en 14 pacientes se utilizó la succinilcolina y en 151, el rocuronio. Quince pacientes presentaron DIT (9%): en 4 fue necesario el Airtraq; de ellos, uno requirió sugammadex y fue posteriormente intubado con fibroscopio. La incidencia de intubación con fibroscopio fue del 1,2% (IC 95%; 0,3-4%). La DIT se asoció a los grados de Mallampati 3-4 (odds ratio: 3 [IC 95%; 1,37-6,8], sensibilidad 33%, especificidad 91%) y a la distancia tiromentoniana < 6 cm (odds ratio: 4,8 [IC 95%; 1,45-16]; sensibilidad 53%; especificidad 79%). Conclusión. El protocolo de rescate de DIT con Frova y Airtraq evitó el rescate con sugammadex excepto en un caso (AU)

An alternative local anaesthesia technique to reduce pain in paediatric patients during needle insertion.

AIM: Pain control, which is necessary during most dental procedures, is administered by injecting a local anaesthetic. Because the injection itself can be painful, the procedure via which pain is reduced warrants continued investigation. Only a few studies regarding the reaction of children to dental needle insertion without the use of topical anaesthetics have been reported. This study was conducted to evaluate the efficacy of the local anaesthetic procedure without topical application as compared to the conventional insertion technique for alleviating pain in children receiving local anaesthesia injections. MATERIALS AND METHODS: For the alternative injection procedure, the dentist quickly and gently pulled or pushed the clean and dried loose tissue at the injection site over the tip of the needle to a depth of 1 to 1.5 mm. When the end of the bevel of the needle tip entered the tissue, a few drops of solution were released, after which the needle was advanced to its proper and intended depth to continue anaesthetic release. RESULTS: There was a significant difference regarding the pain response between the alternative insertion technique (less painful) and the conventional one according to Sound, Eye, and Motor (SEM) scale ratings (P < 0.000). No significant difference was observed in the response between the maxilla and mandible, nor between boys and girls, between the conventional and alternative techniques. CONCLUSION: This alternative technique can reduce discomfort in paediatric dental patients and allow the clinician to administer a superficial local anaesthesia injection before the needle is advanced into deeper tissue. This technique is simple, quick, devoid of additional costs, and potentially more effective than the conventional needle insertion method.

Estudio observacional sobre las técnicas de punción del bloqueo axilar para cirugía de mano en pacientes ambulantes en un hospital universitario: Aportes a la ecografía / No disponible

Objetivos: Valorar el aporte de la ecografía para la realización de bloqueos axilares en cirugía mayor ambulatoria con tres tipos de técnicas. Material y métodos: Estudio observacional, prospectivo en pacientes programados para cirugía de manos. Se construyó una base con datos demográficos, el tipo y eficacia de la técnica en cuanto al bloqueo motor y sensitivo, dolor posoperatorio, el grado de satisfacción y complicaciones asociadas. Las tres técnicas estudiadas fueron el uso de neuroestimulador, el uso de la ecografía y la combinación de ambas. Resultados: Se recogieron 151 casos. 77(51 %) se realizaron con NS solo, 36 (24 %) combinando la técnica de NS con Eco, y 38 (25 %) con Eco solo. 15 (20 %) pacientes puncionados con NS requerían un refuerzo de anestesia local versus 14 (38,9 %) en el grupo NS + Eco y 1 (2,6 %) en el grupo Eco solo (p < 0,001). La técnica combinada NS + Eco ha permitido bajar más el volumen de anestésico local comparado con la técnica Eco sola (NS + Eco: 26,2 ± 7,3; Eco solo: 31,4 ± 5,6; p = 0,001). En las 24 primeras horas posoperatorias, no hubo diferencias significativas en el consumo de analgésicos (p = 0,59). El índice de satisfacción era alto y comparable entre los tres grupos (NS: 8,4 ± 1,7/10; NS + Eco: 8,5 ± 1,9/10; Eco: 9,0 ± 1/10; p = 0,17). No hubo complicaciones ni reingresos a las 24 horas de la realización del bloqueo. Conclusión: La técnica ecográfica es segura y permite aumentar la seguridad del bloqueo con una eficacia equivalente o mejor a la técnica neuroestimulada. En cambio, la combinación de las 2 técnicas, da peores resultados, por lo que no recomendamos su uso (AU)

Objective: Asses the role of ultrasound guided axillary block in hand day case surgery with three different techniques. Materials and methods: we design a prospective, observational study in patients scheduled for day case hand surgery. Demographics data, type and efficiency of technique regarding sensitive and motor block, postoperative pain, satisfaction survey and complications were recorded. Block using neurostimulator (NS), ultrasound guide (US) and the combination of both was evaluated (NS+US). Results: 151 patients were included. 77 (51 %) were performed only by NS, 36 (24 %) using both techniques and 38 (25 %) with US solely. 15 (20 %) patients blocks by NS required an extra dose of local anesthetic in relation to 14 (38.9 %) in NS + US group and only 1 patient (2.6 %) block using US (p < 0.001). The combination technique allow to reduce total volume of local anesthetic used respect US guide block (NS + US: 26.2 ± 7.3; US: 31.4 ± 5.6; p = 0.001). In the first postoperative day, no different in analgesic consumption between three groups was found (p = 0.59).The satisfaction was high and comparable in all patients regardless of the technique used (NS: 8.4 ± 1.7/10; NS + US: 8.5 ± 1.9/10; US: 9.0 ± 1/10; p = 0.17). No complications and readmission was reported. Conclusion: US guided are a safe technique and make possible to increase block safety and efficiency. Nevertheless, the combination technique gives worse results and we should avoid their use (AU)

Local anesthesia part 2: technical considerations.

An earlier paper by Becker and Reed provided an in-depth review of the pharmacology of local anesthetics. This continuing education article will discuss the importance to the safe and effective delivery of these drugs, including needle gauge, traditional and alternative injection techniques, and methods to make injections more comfortable to patients.