RESUMEN
BACKGROUND: Anatomical knowledge dictates that regional anaesthesia after total hip arthroplasty requires blockade of the hip articular branches of the femoral and obturator nerves. A direct femoral nerve block increases the risk of fall and impedes mobilisation. We propose a selective nerve block of the hip articular branches of the femoral nerve by an ultrasound-guided injection in the plane between the iliopsoas muscle and the iliofemoral ligament (the iliopsoas plane). The aim of this study was to assess whether dye injected in the iliopsoas plane spreads to all hip articular branches of the femoral nerve. METHODS: Fifteen cadaver sides were injected with 5 mL dye in the iliopsoas plane guided by ultrasound. Dissection was performed to verify the spread of injectate around the hip articular branches of the femoral nerve. RESULTS: In 10 dissections (67% [95% confidence interval: 38-88%]), the injectate was contained in the iliopsoas plane staining all hip articular branches of the femoral nerve without spread to motor branches. In four dissections (27% [8-55%]), the injection was unintentionally made within the iliopectineal bursa resulting in secondary spread. In one dissection (7% [0.2-32%]) adhesions partially obstructed the spread of dye. CONCLUSION: An injection of 5 mL in the iliopsoas plane spreads around all hip articular branches of the femoral nerve in 10 of 15 cadaver sides. If these findings translate to living humans, injection of local anaesthetic into the iliopsoas plane could generate a selective sensory nerve block of the articular branches of the femoral nerve without motor blockade.
Asunto(s)
Nervio Femoral/metabolismo , Articulación de la Cadera/metabolismo , Bloqueo Nervioso/métodos , Ultrasonografía Intervencional/métodos , Anciano de 80 o más Años , Cadáver , Femenino , Humanos , Inyecciones , MasculinoRESUMEN
BACKGROUND: Major hindfoot and ankle surgery is associated with severe postoperative pain, which is effectively alleviated by combined sciatic and saphenous nerve blockade. Local anaesthetics with added dexamethasone consistently prolongs the duration of pain relief compared to local anaesthetics alone. However, whether the extended duration of pain relief is due to an effect on duration of sensorimotor block per se vs. systemic absorption of the dexamethasone is still not fully elucidated. We aimed to investigate the postoperative duration of sensorimotor blockade with either dexamethasone or saline added to bupivacaine-epinephrine. METHODS: Fifty six patients scheduled for surgery were randomly assigned to a popliteal sciatic nerve block of 18 ml 0.5% bupivacaine-epinephrine with either 2 ml of 0.4% dexamethasone or 2 ml 0.9% normal saline added. Sensory and motor functions were tested every 30 min until normalized nerve functions. Primary outcome was time until complete return of sensorimotor functions. RESULTS: Mean (SD) time until return of normal sensory and motor functions was 26 (6) vs. 16 (4) hours, P < 0.001, postponing block remission by 10 (95% CI: 8-13) hours. Mean (SD) time until first opioid request was 34 (11) vs. 15 (7) hours, P < 0.001, extending first opioid request by 19 (95% CI: 13-25) hours. Total oral morphine equivalents administered 0-48 h differed significantly between the two groups by 39 (95% CI: 23-55) mg. CONCLUSIONS: Addition of 8 mg dexamethasone to 0.5% bupivacaine-epinephrine significantly prolongs the duration of sensorimotor popliteal sciatic nerve blockade, and reduces pain and opioid consumption in patients after major hind foot and ankle surgery.
Asunto(s)
Dexametasona/farmacología , Bloqueo Nervioso , Dolor Postoperatorio/prevención & control , Adulto , Anciano , Tobillo/cirugía , Método Doble Ciego , Femenino , Pie/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Nervio Ciático , Factores de TiempoRESUMEN
Background: The currently best-established ultrasound-guided lumbar plexus block (LPB) techniques use a paravertebral location of the probe, such as the lumbar ultrasound trident (LUT). However, paravertebral ultrasound scanning can provide inadequate sonographic visibility of the lumbar plexus in some patients. The ultrasound-guided shamrock LPB technique allows real-time sonographic viewing of the lumbar plexus, various anatomical landmarks, advancement of the needle, and spread of local anaesthetic injectate in most patients. We aimed to compare block procedure outcomes, effectiveness, and safety of the shamrock vs LUT. Methods: Twenty healthy men underwent ultrasound-guided shamrock and LUT LPBs (2% lidocaineadrenaline 20 ml, with 1 ml diluted contrast added) in a blinded randomized crossover study. The primary outcome was block procedure time. Secondary outcomes were procedural discomfort, number of needle insertions, injectate spread assessed with magnetic resonance imaging, sensorimotor effects, and lidocaine pharmacokinetics. Results: The shamrock LPB procedure was faster than LUT (238 [sd 74] vs 334 [156] s; P=0.009), more comfortable {numeric rating scale 010: 3 [interquartile range (IQR) 24] vs 4 [36]; P=0.03}, and required fewer needle insertions (2 [IQR 13] vs 6 [212]; P=0.003). Perineural injectate spread seen with magnetic resonance imaging was similar between the groups and consistent with motor and sensory mapping. Zero/20 (0%) and 1/19 (5%) subjects had epidural spread after shamrock and LUT (P=1.00), respectively. The lidocaine pharmacokinetics were similar between the groups. Conclusions: Shamrock was faster, more comfortable, and equally effective compared with LUT. Clinical trial registration: NCT02255591
Asunto(s)
Anestésicos Locales/administración & dosificación , Lidocaína/administración & dosificación , Plexo Lumbosacro/efectos de los fármacos , Bloqueo Nervioso/métodos , Ultrasonografía Intervencional/métodos , Adulto , Estudios Cruzados , Humanos , Plexo Lumbosacro/diagnóstico por imagen , Masculino , Valores de Referencia , Método Simple Ciego , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: Popliteal sciatic nerve catheters (PSNCs) are associated with a high frequency of displacement. We aimed to estimate the frequency of catheter displacement after 48 h with magnetic resonance imaging (MRI) in patients with PSNCs after major foot and ankle surgery randomized to catheter insertion either with a short-axis in-plane (SAX-IP) approach perpendicular to the nerve or with a short-axis out-of-plane (SAX-OOP) approach parallel to the nerve. METHODS: Forty patients were randomly allocated to SAX-IP or SAX-OOP PSNC. Ropivacaine 0.75% 20 ml was injected via the catheter followed by ropivacaine 0.2% 10 ml h(-)1 infusion. Correct primary catheter placement was ensured after initial injection of local anaesthetic via the catheter. Forty-eight hours after insertion, MRI was performed after injection of saline with added contrast (Dotarem) via the catheter. The primary outcome was catheter displacement estimated as the frequency of spread of contrast exclusively outside the paraneurium. RESULTS: All patients had correct primary catheter placement. The frequency of displacement 48 h after insertion of the PSNC was 40% when inserted perpendicular to the nerve vs 10% parallel to the nerve (difference was 30 percentage points, 95% CI: 3-53 percentage points). The relative risk of displacement was four times larger (95% CI: 0.8-10, P<0.028) in the SAX-IP vs the SAX-OOP group. The morphine consumption was 150% greater in the SAX-IP compared with the SAX-OOP group. CONCLUSION: Popliteal sciatic nerve catheters for major foot and ankle surgery inserted with ultrasound guidance parallel to the sciatic nerve have a significantly lower frequency of displacement compared with those inserted perpendicular to the nerve. CLINICAL TRIAL REGISTRATION: NCT02200016.
Asunto(s)
Tobillo/cirugía , Catéteres , Pie/cirugía , Imagen por Resonancia Magnética Intervencional/métodos , Vena Poplítea/diagnóstico por imagen , Nervio Ciático/diagnóstico por imagen , Adulto , Anciano , Amidas/administración & dosificación , Anestésicos Intravenosos/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/métodos , Procedimientos Ortopédicos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Estudios Prospectivos , Ropivacaína , Adulto JovenRESUMEN
We compared the transverse and longitudinal approaches to ultrasound-guided identification of the cricothyroid membrane, to determine which was faster and more successful. Forty-two anaesthetists received a one-hour structured training programme consisting of e-learning, a lecture and hands-on training, and then applied both techniques in a randomised, cross-over sequence to obese females with body mass index 39.0 - 43.9 kg.m(-2) . The mean (SD) time to identify the cricothyroid membrane was 24.0 (12.4) s using the transverse technique compared with 37.6 (17.9) s for the longitudinal technique (p = 0.0003). Successful identification of the cricothyroid membrane was achieved by 38 (90%) anaesthetists using either technique. All anaesthetists were successful in identifying the cricothyroid membrane with at least one of the techniques. We advocate the learning and application of these two techniques for identification of the cricothyroid membrane before starting anaesthesia in difficult patients, especially when anatomical landmarks are impalpable. Further use in emergency situations is feasible, if clinicians have experience and the ultrasound machine is readily available.
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Manejo de la Vía Aérea/métodos , Anestesistas/educación , Cartílago Cricoides/diagnóstico por imagen , Obesidad Mórbida/diagnóstico por imagen , Cartílago Tiroides/diagnóstico por imagen , Ultrasonografía Intervencional , Adulto , Estudios Cruzados , Femenino , Humanos , Persona de Mediana EdadRESUMEN
We investigated the effects of pre-operative ultrasound-guided bilateral dual transversus abdominis plane blocks on pain when sitting up and pain at rest after laparoscopic appendicectomy. We allocated 28 participants to injection with 60 ml ropivacaine 0.375% and 28 participants to 60 ml isotonic saline. The median (IQR [range]) cumulative pain scores during the first 12 postoperative hours were less after ropivacaine than saline (maximum 120): on sitting, 34 (19-46 [0-59]) vs 50 (30-59 [0-97]), respectively, p = 0.009; and at rest, 25 (10-33 [0-49]) vs 31 (24-43 [0-72]), respectively, p = 0.035. There were no differences in morphine consumption, nausea, vomiting, time in recovery or time to walk.
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Músculos Abdominales/inervación , Apendicectomía/métodos , Laparoscopía/métodos , Bloqueo Nervioso/métodos , Adulto , Amidas/farmacología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , RopivacaínaAsunto(s)
Músculos Laríngeos/diagnóstico por imagen , Obesidad Mórbida/diagnóstico por imagen , Palpación/métodos , Cartílago Tiroides/diagnóstico por imagen , Adulto , Manejo de la Vía Aérea/métodos , Anestesiología/educación , Estudios Cruzados , Femenino , Humanos , Tráquea/diagnóstico por imagen , Ultrasonografía IntervencionalRESUMEN
The purpose of this study was to investigate the effects of blockade of the saphenous nerve and the posterior branch of the obturator nerve in addition to a standard analgesic regimen for patients discharged the same day after knee arthroscopy. The primary outcome was knee pain on flexion during the first 24 postoperative hours, calculated as area under the curve. We allocated 60 patients to ultrasound-guided nerve blocks with either ropivacaine or saline, 30 to each. The median (IQR [range]) pain score on knee flexion in the ropivacaine group 2.0 (1.1-3.7 [0.1-7.1]) was not statistically different to that in the saline group (3.3 (1.7-4.6 [0.3-6.8]), p = 0.06). There were no differences in pain at rest, opioid consumption or function.
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Artroscopía , Bloqueo Nervioso/métodos , Nervio Obturador , Dolor Postoperatorio/prevención & control , Ultrasonografía Intervencional/métodos , Adulto , Anciano , Procedimientos Quirúrgicos Ambulatorios , Femenino , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Músculos Abdominales , Analgesia Epidural , Colon/cirugía , Laparoscopía/métodos , Bloqueo Nervioso , Recto/cirugía , Femenino , Humanos , MasculinoRESUMEN
Surgical anaesthesia with haemodynamic stability and opioid-free analgesia in fragile patients can theoretically be provided with lumbosacral plexus blockade. We compared a novel ultrasound-guided suprasacral technique for blockade of the lumbar plexus and the lumbosacral trunk with ultrasound-guided blockade of the lumbar plexus. The objective was to investigate whether the suprasacral technique is equally effective for anaesthesia of the terminal lumbar plexus nerves compared with a lumbar plexus block, and more effective for anaesthesia of the lumbosacral trunk. Twenty volunteers were included in a randomised crossover trial comparing the new suprasacral with a lumbar plexus block. The primary outcome was sensory dermatome anaesthesia of L2-S1. Secondary outcomes were peri-neural analgesic spread estimated with magnetic resonance imaging, sensory blockade of dermatomes L2-S3, motor blockade, volunteer discomfort, arterial blood pressure change, block performance time, lidocaine pharmacokinetics and complications. Only one volunteer in the suprasacral group had sensory blockade of all dermatomes L2-S1. Epidural spread was verified by magnetic resonance imaging in seven of the 34 trials (two suprasacral and five lumbar plexus blocks). Success rates of the sensory and motor blockade were 88-100% for the major lumbar plexus nerves with the suprasacral technique, and 59-88% with the lumbar plexus block (p > 0.05). Success rate of motor blockade was 50% for the lumbosacral trunk with the suprasacral technique and zero with the lumbar plexus block (p < 0.05). Both techniques are effective for blockade of the terminal nerves of the lumbar plexus. The suprasacral parallel shift technique is 50% effective for blockade of the lumbosacral trunk.
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Plexo Lumbosacro , Bloqueo Nervioso/métodos , Ultrasonografía Intervencional/métodos , Adulto , Estudios Cruzados , Método Doble Ciego , Voluntarios Sanos , Humanos , Lidocaína/sangre , Imagen por Resonancia Magnética , Estudios ProspectivosRESUMEN
BACKGROUND: Ultrasound (US) may have an emerging role as an adjunct in verification of endotracheal intubation. Obtaining optimal US images in obese patients is generally regarded more difficult than for other patients. This study compared the time consumption of bilateral lung US with auscultation and capnography for verifying endotracheal intubation in obese patients. METHODS: A prospective, paired and investigator-blinded study performed in the operating theatre. Twenty-four adult patients requiring endotracheal intubation for bariatric surgery were included. During post-intubation bag ventilation, bilateral lung US was performed for detection of lungsliding indicating lung ventilation simultaneous with capnography and auscultation of epigastrium and chest. Primary outcome measure was the time difference to confirmed endotracheal intubation between US and auscultation alone. The secondary outcome measure was time difference between US and auscultation combined with capnography. RESULTS: Both methods verified endotracheal tube placement in all patients. No significant difference was found between US compared with auscultation alone. Median time for verification by auscultation alone was 47.5 s [interquartile (IQR) 40-51 s], with a mean difference of -0.3 s in favor of US (95% confidence interval -3.5-2.9 s) P = 0.87. Comparing US with the combination of auscultation and capnography, there was a significant difference between the two methods. Median time for verification by US was 43 s (IQR 40-51 s) vs. 55 s (IQR 46-65 s), P < 0.0001. CONCLUSION: In obese patients, verification of endotracheal tube placement with US is as fast as auscultation alone and faster than the standard method of auscultation and capnography.
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Auscultación/métodos , Capnografía/métodos , Intubación Intratraqueal/métodos , Obesidad/complicaciones , Adulto , Anestesia General , Cirugía Bariátrica , Femenino , Humanos , Laringoscopía , Masculino , Persona de Mediana Edad , Enfermeras Anestesistas , Obesidad/diagnóstico por imagen , Estudios Prospectivos , Respiración Artificial/estadística & datos numéricos , Tamaño de la Muestra , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND: This study compared the time consumption of bilateral lung ultrasound with auscultation and capnography for verifying endotracheal intubation. METHODS: A prospective, paired, and investigator-blinded study carried out in the operating theatre. Twenty-five adult patients requiring endotracheal intubation were included. During intubation, transtracheal ultrasound was performed to visualize passage of the endotracheal tube. During bag ventilation, bilateral lung ultrasound was performed for the detection of lung sliding as a sign of ventilation simultaneous with capnography and auscultation of the epigastrium and chest. Primary outcome measure was time difference to confirmed endotracheal intubation between ultrasound and auscultation alone. Secondary outcome measure was time difference between ultrasound and auscultation combined with capnography. RESULTS: Both methods verified endotracheal tube placement in all patients. In 68% of patients, endotracheal tube placement was visualized by real-time transtracheal ultrasound. Comparing ultrasound with the combination of auscultation and capnography, there was a significant difference between the two methods. Median time for ultrasound was 40 s [interquartile range (IQR) 35-48 s] vs. 48 s (IQR 45-53 s), P < 0.0001. Mean difference was -7.1 s in favour of ultrasound [95% confidence interval (CI) -9.4--4.8 s]. No significant difference was found between ultrasound compared with auscultation alone. Median time for auscultation alone was 42 s (IQR 37-47 s), P = 0.6, with a mean difference of -0.88 s in favour of ultrasound (95% CI -4.2-2.5 s). CONCLUSIONS: Verification of endotracheal tube placement with ultrasound is as fast as auscultation alone and faster than the standard method of auscultation and capnography.
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Auscultación/métodos , Capnografía/métodos , Intubación Intratraqueal/métodos , Tráquea/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Anestesia por Inhalación , Índice de Masa Corporal , Intervalos de Confianza , Femenino , Humanos , Laringoscopía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Respiración Artificial , Tamaño de la Muestra , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía , Adulto JovenRESUMEN
BACKGROUND: We describe a new ultrasound-guided bilateral dual transversus abdominis plane block. Our hypothesis was that we could anaesthetize both the upper (Th6-Th9) and the lower (Th10-Th12) abdominal wall bilaterally using a four-point single-shot technique to provide effective post-operative analgesia. METHODS: A prospective cohort of 25 recovery room patients was included. They had undergone major open or laparoscopic abdominal surgery under general anaesthesia and had severe post-operative pain. The blocks were conducted using a high-frequency linear transducer and a 22 G, 80-mm-long needle. The needle was inserted in-plane from medial to lateral for each injection. Fifteen millilitres of bupivacaine 2.5 mg/ml was injected at each of the four sites. RESULTS: Block performance took on average 16 min (range 10-20 min). The 25 patients reported a reduction of their maximum pain (visual analogue scale 0-10) from a mean of 8.2 to a mean of 2.2 10 min after block performance (P<0.001). They were discharged from the post-anaesthesia care unit after an average of 34 min. Twenty-one patients (84%) did not require any i.v. opioids in the following 6 h. Sixteen patients (64%) were mobilized within 6 h after the block. Data were similar irrespective of open or laparoscopic surgery (P=0.68). CONCLUSION: This new four-point single-shot technique was effective in decreasing severe pain after a major abdominal surgery. The block, although short-lived, facilitated discharge from the post-anaesthesia care unit, few patients required opioids on the day of surgery and mobilization was improved.
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Abdomen/cirugía , Pared Abdominal/inervación , Bloqueo Nervioso/métodos , Dolor Postoperatorio/terapia , Ultrasonografía Intervencional/métodos , Pared Abdominal/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Laparoscopía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
We present a case with an ultrasound-guided (USG) placement of a perineural catheter beneath the transverse scapular ligament in the scapular notch to provide a continuous block of the suprascapular nerve (SSN). The patient suffered from a severe and very painful adhesive capsulitis of the left shoulder secondary to an operation in the same shoulder conducted 20 weeks previously for impingement syndrome and a superior labral anterior-posterior tear. Following a new operation with capsular release, the placement of a continuous nerve block catheter subsequently allowed for nearly pain-free low impact passive and guided active mobilization by the performing physiotherapist for three consecutive weeks. This case and a short topical review on the use of SSN block in painful shoulder conditions highlight the possibility of a USG continuous nerve block of the SSN as sufficient pain management in the immediate post-operative period following capsular release of the shoulder. Findings in other painful shoulder conditions and suggestions for future studies are discussed in the text.