Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. METHODS: Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. RESULTS: There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. CONCLUSIONS: In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov (NCT03069183).

Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus 0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial.

BACKGROUND: Efforts to prolong interscalene block (ISB) analgesia include the use of local anaesthetic adjuvants such as dexamethasone. Previous work showing prolonged block duration suggests that both perineural and intravenous (i.v.) routes can both prolong analgesia. The superiority of either route is controversial given the design of previous studies. As perineural dexamethasone is an off-label use, anaesthesiologists should be fully informed of the clinical differences, if any, on block duration. This study was designed to test whether perineural vs i.v. dexamethasone administration are equivalent. METHODS: We randomised 182 eligible patients scheduled for arthroscopic shoulder surgery to receive low-dose ISB (0.5% ropivacaine 5 ml) with perineural or i.v. dexamethasone 4 mg. Subjects, anaesthesiologists, and research personnel were blinded. All subjects also received a standardised general anaesthetic and multimodal analgesia. The primary outcome was duration of analgesia analysed as an equivalence outcome (2 h equivalency margin) using the two one-sided test (TOST) method. RESULTS: For the primary outcome, duration of analgesia, and perineural and i.v. administration of dexamethasone were not equivalent. The upper and lower bounds of the 90% confidence interval were 1 h (P=0.12) and -2.5 h (P=0.01), respectively. The observed difference in mean block duration was not clinically relevant (0.75 h longer for i.v. dexamethasone). There were no other clinically significant differences between groups. CONCLUSION: In the context of low-volume ISB with ropivacaine, perineural and i.v. dexamethasone were not equivalent in terms of their effects on block duration. However, there were no clinically significant differences in outcomes, and there is no advantage of perineural over intravenous dexamethasone. WWW.CLINICALTRIALS. GOV REGISTRATION: NCT02322242.

Analysis of Inpatient Falls After Total Knee Arthroplasty in Patients With Continuous Femoral Nerve Block.

Continuous femoral nerve block (cFNB) is thought to increase the risk of falls after total knee arthroplasty (TKA). Previous studies have failed to consider the timing of cFNB removal in relation to inpatient falls. We investigated all inpatient falls after TKA over a 3-year period using our institutional safety report database. Ninety-five falls were reported from a total of 3745 patients. The frequency of falls after TKA persisted at a similar rate despite removal of cFNB and likely regression of femoral nerve block. Other modifiable risk factors may play a more prominent role in falls risk after TKA.

Randomized control trial of a holographic needle guidance technique for thoracic epidural placement.

INTRODUCTION: The Microsoft HoloLens is a head-mounted mixed reality device, which allows for overlaying hologram-like computer-generated elements onto the real world. This technology can be combined with preprocedural ultrasound during thoracic epidural placement to create a visual of the ideal needle angulation and trajectory in the users' field of view. This could result in a technically easier and potentially safer alternative to traditional blind landmark techniques. METHODS: Patients were randomly assigned to one of two groups: (1) HoloLens-assisted thoracic epidural technique (intervention-group H) or (2) traditional thoracic epidural technique (control-group C). The primary outcome was needling time (defined as skin puncture to insertion of epidural catheter) during the procedure. The secondary outcomes were number of needle punctures, number of needle movements, number of bone contacts, and epidural failure. Procedural pain and recovery room pain levels were also evaluated. RESULTS: Eighty-three patients were included in this study. The primary outcome of procedure time was reduced in the HoloLens group compared with control (4.5 min vs 7.3 min, p=0.02, 95% CI), as was the number of needle movements required (7.2 vs 14.4, p=0.01), respectively. There was no difference in intraprocedure or postprocedure pain, bone contacts, or total number of needle punctures. Three patients in the control group experienced epidural failure versus one patient in the HoloLens group. CONCLUSIONS: This study shows that thoracic epidural placement may be facilitated by using a guidance hologram and may be more technically efficient. TRIAL REGISTRATION NUMBER: NCT04028284.

Genicular nerve and fracture site chemical neurolysis for distal femoral fracture: a case report.

BACKGROUND: Distal femur fractures account for approximately 3%-6% of all femoral fractures. Non-operative management may be an attractive option for the elderly with significant perioperative mortality risk. Adequate pain control is a major barrier to non-operative fracture management. Chemical neurolysis has been described for analgesic management of proximal hip fractures, however no description of interventional management of distal femur fracture exists in literature. We describe a case of phenol chemical neurolysis of genicular nerves in addition to injection at the site of fracture to provide effective analgesia for distal femur fracture. CASE PRESENTATION: A patient in their 90s with a witnessed mechanical fall sustained an intra-articular displaced fracture of the distal right femur shaft with extension into the distal femoral condyle. The patient elected to undergo non-surgical management given the high perioperative mortality risk. Acute pain service was involved and multimodal oral analgesics including opioids were insufficient in managing the patient's pain. The addition of femoral nerve catheter local anesthetic infusion did not sufficiently improve analgesia. Phenol chemical neurolysis of the superolateral, superomedial, inferomedial genicular nerves and of the fracture site was offered and performed. Resting pain decreased from Numerical Rating Scale 5/10 to 0/10 on postprocedure day 1. This was sustained at the 2-month timepoint. CONCLUSIONS: We report the successful use of phenol neurolysis of genicular nerves and the fracture site in an elderly patient with a conservatively managed distal femur fracture. These interventions resulted in improved analgesia and achieved prolonged duration of effect.

Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report.

BACKGROUND: Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia. CASE PRESENTATION: A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize. CONCLUSION: Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

Ultrasound detection of iatrogenic injury during peribulbar eye block: a cadaveric study.

BACKGROUND: Ophthalmic eye blocks, such as retrobulbar, peribulbar and sub-Tenon's, are traditionally conducted "blind". Complications are rare but potentially devastating. Life-threatening complications include brain stem anesthesia and local anesthetic toxicity, whereas sight-threatening complications include globe perforation, optic nerve damage and ocular muscle damage. Ultrasound permits a view of orbital structures and can be used to guide needle placement. The ultrasound appearances of unintended local anesthetic injection into vital orbital structures have not been documented. This study aimed to record the ultrasound appearances of unintended injection locations. METHODS: The spherical shape of the eyeballs of three soft-fix Thiel embalmed human cadavers were restored using glycerol. Iatrogenic injury in peribulbar block was then simulated through injection of printers' ink mixed with Thiel embalming fluid. Ultrasound was used to guide the needles and the tips were redirected to lie within the globe, lateral rectus and optic nerve. Ultrasound images were recorded during injection. The orbital cavities were then dissected via a superior approach to record the location and extent of injectate spread. RESULTS: Real-time globe rupture, ocular muscle injection and optic nerve injection were visible using ultrasound. Characteristic appearances were identified in each case. Dissection confirmed needle and injection placement. CONCLUSIONS: The ultrasound appearance of block complications is important to document and should be an integral part of regional anesthesia training. This study is the first to provide such images for ophthalmic nerve blocks. It offers ophthalmic anesthetists and ophthalmologists the potential to diagnose severe complications rapidly and accurately with a potential impact on patient safety.

Survey of international regional anesthesia fellowship directors.

BACKGROUND: The scope of regional anesthesia fellowship programs has not been analyzed but may provide insights that could improve fellowship training and standards. METHODS: Regional anesthesia fellowship directors across the world were asked to complete a comprehensive survey that detailed the range of educational and practical experience and attitudes as well as assessment procedures offered in their programs. RESULTS: The survey response rate was 66% (45/68). Overall, the range of activities and the time and resources committed to education during fellowships is encouraging. A wide range of nerve block experience is reported with most programs also offering acute pain management, research, and teaching opportunities. Only two-thirds of fellowships provide formal feedback. This feedback is typically a formative assessment. CONCLUSION: This is the first survey of regional anesthesia fellowship directors, and it illustrates the international scope and continuing expansion of education and training in the field. The results should be of interest to program directors seeking to benchmark and improve their educational programs and to faculty involved in further curriculum development.