Comparison of ultrasonography-guided lateral versus medial costoclavicular brachial plexus block in pediatric patients : A randomized clinical trial.

BACKGROUND AND AIMS: Costoclavicular brachial plexus block is gaining popularity due to its ease of application. Lateral and medial costoclavicular approaches have recently been defined. In the current study, we aimed to investigate the procedural execution of these approaches in the pediatric population. METHODS: In this study 55 children aged between 2 and 10 years were randomized to receive lateral (LC group) or medial (MC group) costoclavicular brachial plexus block after induction of general anesthesia for postoperative analgesia. All patients received bupivacaine (1 mg/kg, 0.25%) within the center of the cord cluster. The number of needle maneuvers was recorded as primary outcome. Block performing features (ideal ultrasound-guided brachial plexus cords visualization, needle pathway planning time, needle tip and shaft visualization difficulty, requirement of extra needle maneuver due to insufficient local anesthetic distribution, block performance time, total procedure difficulty) and postoperative pain-related data (block intensities, pain scores and analgesic requirements) were all compared as secondary outcomes. RESULTS: The LC group patients required less ultrasound visualization time (median 14 s, range 11-23 s vs. median 42 s, range 15-67 s, p < 0.001) and fewer needle maneuvers (median 1, range 1-2 vs. median 3, range 2-4, p < 0.001) compared to the MC group. Similarly, the median block performance duration was shorter (median 67 s, range 47-94 s vs. median 140s, 90-204 s, p < 0.01) and procedures were perceived as easier (median 4, range 4-5 vs. median 3, range 2-5, p = 0.04) in the LC group. All other parameters were comparable (p > 0.05). CONCLUSION: The lateral approach required less needle maneuvers than the medial approach. Both techniques represented a good safety profile with favorable analgesic features.

Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study.

BACKGROUND: Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients. METHODS: Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated. RESULTS: Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05). CONCLUSIONS: US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . TRIAL REGISTRATION: NCT04596787.

Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty: A Historical Cohort Study.

BACKGROUND: This study investigates whether ultrasound-guided thoracic paravertebral blocks would improve postoperative analgesia in patients undergoing bilateral reduction mammaplasty. METHODS: After obtaining ethics committee approval, data of 70 patients who underwent bilateral reduction mammaplasty were reviewed. Sixty-four patients' data were evaluable; 30 were in the general anesthesia group and 34 were in the thoracic paravertebral block group. Data such as time to first pain, intraoperative fentanyl requirement, postoperative numeric rating scale scores, number of patients who required tramadol in the postoperative care unit, and rescue analgesic consumption through the first 2 postoperative days were analyzed. RESULTS: Time to first pain was 311 minutes (range, 0 to 1605 minutes) and 20 minutes (range, 0 to 120 minutes) in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Fentanyl requirement was 52.94 ± 11.94 µg and 115 ± 29.79 µg in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Numeric rating scale scores were lower in the thoracic paravertebral block group through the first 2 postoperative hours (p < 0.001), and only two of 34 patients required tramadol in the postoperative care unit (p < 0.001). On postoperative day 1, both metamizole sodium (p < 0.001) and paracetamol (p = 0.018), and on day 2, only metamizole sodium (p < 0.001) consumption was lower in the thoracic paravertebral block group. CONCLUSION: Adding ultrasound-guided thoracic paravertebral blocks to general anesthesia postponed time to first pain and reduced analgesic consumption in patients undergoing bilateral reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers.

BACKGROUND AND OBJECTIVES: Adductor canal block (ACB) has been suggested as an analgesic alternative to femoral nerve block (FNB) for procedures on the knee, but its effect on quadriceps motor function is unclear. We performed a randomized, blinded study to compare quadriceps strength following adductor canal versus FNB in volunteers. Our hypothesis was that quadriceps strength would be preserved following ACB, but not FNB. Secondary outcomes included relative preservation of hip adduction and degree of balance impairment. METHODS: The ACB was performed in one leg and the FNB in the contralateral leg in 16 volunteers using a randomized block sequence. For all blocks, 15 mL of 3% chloroprocaine was injected under ultrasonographic guidance. Maximal voluntary isometric contraction of knee extension and hip adduction was measured at baseline and at 30 and 60 minutes after block. After 60-minute assessments were complete, the second block was placed. A test of balance (Berg Balance Scale) was performed 30 minutes after the first block only. RESULTS: Quadriceps strength and balance scores were similar to baseline following ACB. Following FNB, there was a significant reduction in quadriceps strength (95.1% ± 17.1% vs 11.1% ± 14.0%; P < 0.0001) and balance scores (56 ± 0 vs 37 ± 17.2; P = 0.02) compared with baseline. There was no difference in hip adductor strength (97.0% ± 10.8% vs 91.8% ± 9.6%; P = 0.17). CONCLUSIONS: Compared with FNB, ACB results in significant quadriceps motor sparing and significantly preserved balance.

Effective volume of ropivacaine 0.75% through a catheter required for interscalene brachial plexus blockade.

BACKGROUND: Ultrasound guidance during peripheral nerve blocks has allowed for reduction in dose and volume of local anesthetic required to accomplish successful blockade using multiple injections through a needle. The authors undertook this study to determine the minimal effective volume required to accomplish successful interscalene brachial plexus block (ISB) through the catheter. METHODS: After obtaining institutional ethics committee approval and written informed consent, patients aged 18-75 yr and scheduled for arthroscopic shoulder surgery under ISB were enrolled. All patients using a step-up/step-down method and the starting dose of 15 ml of 0.75% ropivacaine received an ultrasound-guided ISB catheter. The injection volume was increased or decreased by 1 ml in case of block failure or block success, respectively. RESULTS: The authors found that the proportion of patients with successful blockade increased sharply from approximately 57% at 6 ml to 100% by 7 ml, indicating that a small increase in volume of ropivacaine 0.75% markedly affects the success rate. A total of 12 ISB with injection volume less than 7 ml resulted in successful anesthesia within 30 min, yielding an ED95 of 7 ml (95% CI 6.8-7.2) ropivacaine 0.75%. For the group as a whole, the median (min-max) sensory block onset time was 5 (5-20) min, the median (min-max) motor blocks for the biceps and the deltoid muscles were 7.5 (5-15) min and 10 (5-15) min, respectively. The median (min-max) block duration was 8.9 (3-15) h. CONCLUSIONS: An injection of a minimum of 7 ml of ropivacaine 0.75% through the catheter is required for success rate and timely onset of surgical anesthesia with ISB.