Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults.

PURPOSE: This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults. PATIENTS AND METHODS: Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUCVAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes. RESULTS: At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUCVAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUCVAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group. CONCLUSION: cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Continuous Peripheral Nerve Blocks for Early Active Mobilization after Hand Surgery: Four Case Reports.

Early active mobilization after hand surgery is extremely important for preventing scar tissue and adhesion. We examined four patients for whom continuous peripheral nerve blocks (CPNB) were used during and after hand surgery. This method was used for three median nerves and one ulnar nerve. A 2-cm incision was made at distal one-third of the forearm with local analgesia. The catheter tip was placed in the distal one-fourth of the forearm, and the hand surgery was begun. Early active mobilization and the self-rehabilitation exercise started immediately after the operation. The VAS scores during exercise were 0-2 (mean: 1.3); pain was controlled sufficiently. Regarding ROM, excellent results were obtained for tenolysis, with good results for arthrolysis. No infection or postoperative nerve compression was found. This method, using CPNB with a portable infusion pump, is effective and safe for use at home for postoperative pain control.

The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine vs 0.2% ropivacaine on pain relief, diaphragmatic motility, and ventilatory function.

STUDY OBJECTIVE: Outpatient continuous interscalene brachial plexus blocks containing bupivacaine or ropivacaine are commonly used to control pain after shoulder surgery. Interscalene blocks cause hemidiaphragmatic paresis. Because ropivacaine preferentially blocks sensory fibers, it may cause less blockade of the phrenic nerve. The purpose of this study was to evaluate the effects of 2 common continuous interscalene brachial plexus infusions: 0.125% bupivacaine vs 0.2% ropivacaine. The study hypothesis is that respiratory function will be less attenuated using ropivacaine than bupivacaine without affecting pain relief. DESIGN: Study design was a prospective randomized double-blind study, registered (NCT 02059070), with institutional review board approval and written informed consent. SETTING: The setting was the preoperative and postoperative area in an orthopedic teaching hospital. PATIENTS: Outpatients scheduled for shoulder arthroscopic surgery were included. INTERVENTIONS: All patients underwent baseline measurements and interscalene catheter placement, then randomized to receive pumps containing either 0.2% ropivacaine or 0.125% bupivacaine. MEASUREMENTS: Study measurements included preoperative and postoperative bedside spirometry and ultrasonographic evaluations of diaphragmatic excursion, postoperative pain scores, and postdischarge oral opioid (oxycodone) consumption. MAIN RESULTS: There were no statistically significant differences between bupivacaine vs ropivacaine in outcomes of forced expiratory volume at 1 second change (-22% ± 18.3% vs -29% ± 14.9%), diaphragmatic excursion (-81.4% ± 37.95% vs -75.5% ± 35.1%), VAS pain scores at rest (4.9 ± 2.9 vs 3.5 ± 2.8), or oral opioid consumption (33.7 ± 24.3 mg vs 35.1 ± 33.9 mg). CONCLUSIONS: There was no difference in respiratory dysfunction or opioid requirements between interscalene continuous peripheral nerve blocks with 0.125% bupivacaine or 0.2% ropivacaine. Further study is required to identify anesthetic infusates that will control pain while decreasing the attenuation of pulmonary function.

Peripheral nerve blocks for ambulatory surgery.

Peripheral nerve blocks (PNBs) provide significant improvement in postoperative analgesia and quality of recovery for ambulatory surgery. Use of continuous PNB techniques extend these benefits beyond the limited duration of single-injection PNBs. The use of ultrasound guidance has significantly improved the overall success, efficiency, and has contributed to the increased use of PNBs in the ambulatory setting. More recently, the use of ultrasound guidance has been demonstrated to decrease the risk of local anesthetic systemic toxicity. This article provides a broad overview of the indications and clinically useful aspects of the most commonly used upper and lower extremity PNBs in the ambulatory setting. Emphasis is placed on approaches that can be used for single-injection PNBs and continuous PNB techniques.

Internet remote control of pump settings for postoperative continuous peripheral nerve blocks: a feasibility study in 59 patients.

INTRODUCTION: During continuous peripheral nerve blocks, infusion adjustments are essential for postoperative analgesia without side effects. Beside, physicians and nurse visits related to pump's settings and monitoring are time consuming and costly. We hypothesized that a remote control of pump's settings, by telemedicine transmission, adjusted to patients' feedbacks, is feasible and interesting in optimizing patient's postoperative pain management. METHODS: Fifty-nine ASA physical status I and II patients were included. Ropivacaine 0.2% was infused during 72 h in CPNB catheters. After returning to the surgical ward, the patient was allowed to answer a 10 indicators questionnaire 3 times a day (8.00 AM, 2.00 PM, 8.00 PM), or unlimited on patient's demand. This information was transmitted from the pump to a server through the Internet. If one indicator was out of the predefined thresholds, the anesthesiologist in charge was immediately informed by texto on his cell phone. The anesthesiologist connected to the website, checked the data from the patient and modified the settings of the pump by remote control according to a written protocol. The changes need a secure access with a password and a confirmation. The number of settings changes, the time to realize the procedure and the adverse events related to the technique were noted. When the catheter was removed, the pump was unassigned to the patient and the data archived. RESULTS: Thirty sciatic, 24 femoral and 5 interscalene catheters were inserted in 59 patients. Five catheters were accidentally removed before the end of the 72-h period. The median VAS pain values at rest and during movement were respectively at 2 and 3. Sixteen patients complained about numbness promoting 2 (0-3) changes in pump settings; 9 about motor blockade with 1 (0-2) change; 5 about difficulties for physiotherapy with 1 (0-3) change. The mean time of pump settings modification after response to questionnaire or voluntarily patient's alert was 15 ± 2.2 minutes. Early physiotherapy in the surgical ward was totally uneventful in 54 patients. The mean value of satisfaction scale of the patients was 8.4 ± 1.6. No adverse event necessitated a postoperative analgesia technique change. CONCLUSION: Remote control pump's feedbacks and e-settings for postoperative analgesia using CPNB permitted a real adaptation to patients' needs, complaints and pain VAS values without nurse and physician physical intervention.