RESUMO
BACKGROUND: Although obese patients benefit from neuraxial anesthesia, technical difficulties often discourage its use. The current randomized trial compared Accuro, a hand-held, battery-operated ultrasound (US) device, and conventional palpation for spinal anesthesia in obese patients undergoing orthopedic surgery. We hypothesized that Accuro would decrease the number of needle redirections. METHODS: We enrolled 130 men and women with a body mass index ≥30 kg/m2, scheduled for lower limb surgery under spinal block. Patients were randomized either to the Control group (group C: spinal block after palpation of cutaneous landmarks) or to the Accuro group (group A: preprocedural US scan with Accuro to identify the needle insertion point). The procedural time, the number of skin passes and of needle redirections, the occurrence of failure and adverse events were recorded. RESULTS: Ninety-nine patients completed the study. Patients in group Accuro showed a median (IQR) number of redirections of 3 (0-9) and a median (IQR) number of needle passes through the skin of 1 (1-2) versus 6 (1-16) and 1 (1-3), respectively, in group Control (p=0.008, p=0.019). The performance time was 558±232 s in group Accuro versus 348±255 s in group Control (p<0.001). There were no intergroup differences in terms of failed blocks and adverse events. CONCLUSIONS: The use of Accuro reduced the number of needle redirections and passes through the skin when performing spinal anesthesia, but required a longer procedural time. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registry (NCT03075488).
RESUMO
BACKGROUND: Phantom limb syndrome (PLS) is common after limb amputations, involving up to 90% of amputees. Although many different therapies have been evaluated, none has been found to be highly effective. Therefore, we evaluated the efficacy of a prolonged perineural infusion of a high concentration of local anesthetic solution in preventing PLS. METHODS: A perineural catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperatively at 5 mL/h using an elastomeric (nonelectronic) pump, and continued for 4 to 83 days after surgery. PLS was evaluated on the first postoperative day and then 1, 2, 3, and 4 weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours before each assessment period (i.e., until the sensation in the extremity returned). The severity of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 = no pain to 4 = intolerable pain, and "phantom" sensations were recorded as present or absent. If the VRS score was >1 or significant phantom sensations were present, the ropivacaine infusion was immediately restarted at 5 mL/h. If the VRS score remained at 0 to 1 and the patient had not experienced phantom sensations for 48 hours, the infusion was permanently discontinued and the catheter was removed. RESULTS: Median duration of the local anesthetic infusion was 30 days (95% confidence interval, 25-30 days). On postoperative day 1, 73% of the patients complained of severe-to-intolerable pain (visual analog scale >2). However, the incidence of severe-to-intolerable phantom limb pain was only 3% at the end of the 12-month evaluation period. At the end of the 12-month period, the percentage of patients with VRS pain scores were 0 = 84%, 1 = 10%, 2 = 3%, 3 = 3%, and 4 = none. However, phantom limb sensations were present in 39% of patients at the end of the 12-month evaluation period. All patients were able to manage the elastomeric catheter infusion system at home. CONCLUSION: Use of a prolonged postoperative perineural infusion of ropivacaine 0.5% seems to be an effective therapy for the treatment of phantom limb pain and sensations after lower extremity amputation.
