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1.
Pain ; 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33021563

RESUMO

Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

2.
J Perioper Pract ; : 1750458920903647, 2020 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-32096444

RESUMO

Opioids are an indispensable component of perioperative pain management; however, the burgeoning opioid epidemic necessitates research into the risk factors for the development of opioid dependence and abuse following surgery. Diabetes has been identified as a risk factor for prolonged opioid utilisation following non-orthopaedic surgery; however, this association has not been investigated following orthopaedic surgery. To bridge this gap in the literature, we performed a retrospective propensity-matched cohort study in patients undergoing primary unilateral total hip arthroplasty. Propensity-matched cohorts were created to compare patients with and without preexisting diabetes mellitus. Outcomes of interest were opioid utilisation and subjective pain on postoperative day 1. Our results did not identify an association between preexisting diabetes and postoperative pain or opioid utilisation. While this study did not identify an association between diabetes and opioid utilisation following total hip arthroplasty, future studies should pursue a prospective, longitudinal approach and investigate other common orthopaedic procedures.

3.
Reg Anesth Pain Med ; 45(4): 260-266, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31969443

RESUMO

BACKGROUND: Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique. METHODS: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB. RESULTS: Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI -3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI -1.2 to -0.1; p=0.0043). No block-related adverse events occurred in either group. CONCLUSIONS: PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1-2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery. TRIAL REGISTRATION NUMBER: NCT03549234.

4.
Korean J Anesthesiol ; 73(2): 163-168, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31475505

RESUMO

BACKGROUND: Acute post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration measured in multiple weeks. CASE: We report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy. Across all postoperative days and all three patients, the mean pain score on the numeric rating scale was 0 for each day. Similarly, no patient required any supplemental opioid analgesics during the entire postoperative period; and, no patient reported insomnia or awakenings due to pain at any time point. This was a significant improvement over historic cohorts. CONCLUSIONS: Ultrasound-guided percutaneous cryoanalgesia is a potential novel analgesic modality for acute pain management which has a duration that better-matches mastectomy than other currently-described techniques. Appropriately powered randomized, controlled clinical trials are required to demonstrate and quantify both potential benefits and risks.

5.
Anesth Analg ; 128(6): e104-e108, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094804

RESUMO

We tested the hypothesis that during a continuous popliteal-sciatic nerve block, postoperative analgesia is improved with the catheter insertion point "deep" to the paraneural sheath immediately distal to the bifurcation between the tibial and common peroneal branches, compared with the traditional approach "superficial" to the paraneural sheath proximal to the bifurcation. The needle tip location was determined to be accurately located with a fluid bolus visualized with ultrasound; however, catheters were subsequently inserted without a similar fluid injection and visualization protocol (visualized air injection was permitted and usually implemented, but not required per protocol). The average pain (0-10 scale) the morning after surgery for subjects with a catheter inserted at the proximal subparaneural location (n = 31) was a median (interquartile) of 1.5 (0.0-3.5) vs 1.5 (0.0-4.0) for subjects with a catheter inserted at the distal supraparaneural location (n = 32; P = .927). Secondary outcomes were similarly negative.


Assuntos
Analgesia/métodos , Cateterismo/métodos , Bloqueio Nervoso , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Nervo Isquiático/efeitos dos fármacos , Adulto , Idoso , Anestésicos Locais , Cateteres , Feminino , Humanos , Injeções , Lidocaína/administração & dosagem , Masculino , Pessoa de Meia-Idade , Agulhas , Medição da Dor , Período Pós-Operatório , Estudos Prospectivos
6.
Reg Anesth Pain Med ; 2019 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-30770421

RESUMO

BACKGROUND AND OBJECTIVES: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period. METHODS: Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28. RESULTS: Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported. CONCLUSIONS: This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture. TRIAL REGISTRATION NUMBER: NCT02898103.

7.
Neuromodulation ; 22(5): 653-660, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30024078

RESUMO

INTRODUCTION: The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS: For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS: In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS: This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.


Assuntos
Artroplastia do Joelho/efeitos adversos , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico por imagem , Dor Pós-Operatória/terapia , Estimulação Elétrica Nervosa Transcutânea/métodos , Atividades Cotidianas , Idoso , Artroplastia do Joelho/tendências , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/tendências , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Estimulação Elétrica Nervosa Transcutânea/tendências , Resultado do Tratamento , Ultrassonografia de Intervenção/métodos , Ultrassonografia de Intervenção/tendências
8.
Neuromodulation ; 22(5): 621-629, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30160335

RESUMO

OBJECTIVES: The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. MATERIALS AND METHODS: Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5-min crossover period, and then continuous active stimulation until lead removal postoperative Day 14-28. Statistics were not applied to the data due to the small sample size of this feasibility study. RESULTS: During the initial 5-min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5-min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1-3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. CONCLUSIONS: This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Estudo de Prova de Conceito , Estimulação Elétrica Nervosa Transcutânea/métodos , Ultrassonografia de Intervenção/métodos , Adulto , Procedimentos Cirúrgicos Ambulatórios/tendências , Analgesia/métodos , Analgesia/tendências , Reconstrução do Ligamento Cruzado Anterior/tendências , Estudos Cross-Over , Método Duplo-Cego , Eletrodos Implantados/tendências , Feminino , Nervo Femoral/diagnóstico por imagem , Nervo Femoral/fisiologia , Humanos , Masculino , Medição da Dor/métodos , Medição da Dor/tendências , Dor Pós-Operatória/diagnóstico por imagem , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Estimulação Elétrica Nervosa Transcutânea/tendências , Ultrassonografia de Intervenção/tendências
9.
J Clin Anesth ; 51: 32-36, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30075351

RESUMO

STUDY OBJECTIVE: We sought to develop a predictive model for discharge to post-acute care facilities in patients undergoing unilateral total hip replacement (THR). Furthermore, we sought to determine if the use of neuraxial anesthesia was an important covariate for the predictive model. DESIGN: Retrospective observational study. SETTING: Preoperative care and operating room at a single institution. PATIENTS: Patients (n = 960) who underwent an elective primary THR between 2014 and 2016. INTERVENTIONS: No intervention was performed. MEASUREMENTS: We collected variables that were known preoperatively including age, sex, body mass index (BMI), preoperative opioid use, functional status based on metabolic equivalents (METS), preoperative anemia, thrombocytopenia, osteoarthritis and contralateral osteoarthritis grade, anesthesia type, comorbidities and surgical approach. We then performed multivariable logistic regression to develop a predictive model. MAIN RESULTS: Female sex, preoperative opioid use, older age, general anesthesia, anemia, hypertension, a psychiatric diagnosis, use of dialysis, metabolic equivalents <4 and obesity are all risk factors for a post-acute facility discharge. The use of general anesthesia compared to neuraxial anesthesia was associated with increased odds (odds ratio 1.98, 95% confidence interval 1.31-3.00, p = 0.001) for post-acute facility discharge. Model performance was assessed using ten-fold cross-validation - the average area under the receiver operating characteristic curve calculated was 0.794. CONCLUSIONS: We developed a predictive model for post-acute care facility discharge following THR. The use of neuraxial anesthesia was associated with decreased odds for post-acute care facility discharge.


Assuntos
Anestesia Geral/estatística & dados numéricos , Artroplastia de Quadril/efeitos adversos , Bloqueio Nervoso/estatística & dados numéricos , Dor Pós-Operatória/terapia , Cuidados Semi-Intensivos/estatística & dados numéricos , Fatores Etários , Idoso , Artroplastia de Quadril/economia , Feminino , Nível de Saúde , Humanos , Modelos Logísticos , Masculino , Equivalente Metabólico , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/economia , Transferência de Pacientes/estatística & dados numéricos , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Fatores Sexuais , Cuidados Semi-Intensivos/economia
10.
Reg Anesth Pain Med ; 43(6): 580-589, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29905630

RESUMO

BACKGROUND AND OBJECTIVES: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. METHODS: Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. RESULTS: During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. CONCLUSIONS: This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. CLINICAL TRIAL REGISTRATION: This study was registered at Clinicaltrials.gov, identifier NCT02898103.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Hallux Valgus/cirurgia , Dor Pós-Operatória/prevenção & controle , Estudo de Prova de Conceito , Nervo Isquiático , Estimulação Elétrica Nervosa Transcutânea/métodos , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Estudos Cross-Over , Método Duplo-Cego , Feminino , Hallux Valgus/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico por imagem , Projetos Piloto , Nervo Isquiático/diagnóstico por imagem , Nervo Isquiático/fisiologia
11.
Anesth Analg ; 127(1): 240-246, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29750695

RESUMO

BACKGROUND: A continuous adductor canal block provides analgesia after surgical procedures of the knee. Recent neuroanatomic descriptions of the thigh and knee led us to speculate that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal catheter location. We therefore tested the hypothesis that during a continuous adductor canal nerve block, postoperative analgesia would be improved by placing the perineural catheter tip 2-3 cm cephalad to where the femoral artery descends posteriorly to the adductor hiatus (distal location) compared to a more proximal location at the midpoint between the anterior superior iliac spine and the superior border of the patella (proximal location). METHODS: Preoperatively, subjects undergoing total knee arthroplasty received an ultrasound-guided perineural catheter inserted either in the proximal or distal location within the adductor canal in a randomized, subject-masked fashion. Subjects received a single injection of lidocaine 2% via the catheter preoperatively, followed by an infusion of ropivacaine 0.2% (8 mL/h basal, 4 mL bolus, 30 minutes lockout) for the study duration. After joint closure, the surgeon infiltrated the entire joint using 30 mL of ropivacaine (0.5%), ketorolac (30 mg), epinephrine (5 µg/mL), and tranexamic acid (2 g). The primary end point was the median level of pain as measured on a numeric rating scale (NRS) during the time period of 8:00 AM to 12:00 PM the day after surgery. RESULTS: For the primary end point, the NRS of subjects with a catheter inserted at the proximal location (n = 24) was a median (10th, 25th-75th, 90th quartiles) of 0.5 (0.0, 0.0-3.2, 5.0) vs 3.0 (0.0, 2.0-5.4, 7.8) for subjects with a catheter inserted in the distal location (n = 26; P = .011). Median and maximum NRSs were lower in the proximal group at all other time points, but these differences did not reach statistical significance. There were no clinically relevant or statistically significant differences between the treatment groups for any other secondary end point, including opioid consumption and ambulation distance. CONCLUSIONS: For continuous adductor canal blocks accompanied by intraoperative periarticular local anesthetic infiltration, analgesia the day after knee arthroplasty is improved with a catheter inserted at the level of the midpoint between the anterior superior iliac spine and the superior border of the patella compared with a more distal insertion closer to the adductor hiatus.


Assuntos
Anestésicos Locais/administração & dosagem , Artroplastia do Joelho/efeitos adversos , Cateteres de Demora , Lidocaína/administração & dosagem , Bloqueio Nervoso/instrumentação , Dor Pós-Operatória/prevenção & controle , Ropivacaina/administração & dosagem , Idoso , Anestésicos Locais/efeitos adversos , California , Desenho de Equipamento , Feminino , Humanos , Lidocaína/efeitos adversos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/métodos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Ropivacaina/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
12.
A A Pract ; 11(5): 118-120, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-29634527

RESUMO

We present the case of a 55-year-old woman undergoing a delayed latissimus dorsi flap breast reconstruction after a simple mastectomy for breast cancer. Preoperatively, 2 unilateral paravertebral catheters were placed at T3/4 and T7/8 for postoperative analgesia. Postoperatively, ropivacaine 0.2% was infused until the day of discharge on postoperative day 2. The patient had excellent postoperative analgesia and required no opioids or other analgesics through postoperative day 10. We report that multilevel paravertebral nerve blockade could represent an opioid-sparing alternative for postoperative analgesia for latissimus dorsi flap breast reconstruction patients.


Assuntos
Analgesia , Anestésicos Locais , Mamoplastia , Bloqueio Nervoso , Ropivacaina , Feminino , Humanos , Pessoa de Meia-Idade , Retalhos Cirúrgicos , Nervos Torácicos , Vértebras Torácicas
15.
Anesth Analg ; 125(2): 711-713, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28661923
16.
Anesth Analg ; 124(4): 1298-1303, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28319550

RESUMO

BACKGROUND: It remains unknown whether continuous or scheduled intermittent bolus local anesthetic administration is preferable for transversus abdominis plane (TAP) catheters. We therefore tested the hypothesis that when using TAP catheters, providing local anesthetic in repeated bolus doses increases the cephalad-caudad cutaneous effects compared with a basal-only infusion. METHODS: Bilateral TAP catheters (posterior approach) were inserted in 24 healthy volunteers followed by ropivacaine 2 mg/mL administration for a total of 6 hours. The right side was randomly assigned to either a basal infusion (8 mL/h) or bolus doses (24 mL administered every 3 hours for a total of 2 bolus doses) in a double-masked manner. The left side received the alternate treatment. The primary end point was the extent of sensory deficit as measured by cool roller along the axillary line at hour 6 (6 hours after the local anesthetic administration was initiated). Secondary end points included the extent of sensory deficit as measured by cool roller and Von Frey filaments along the axillary line and along a transverse line at the level of the anterior superior iliac spine at hours 0 to 6. RESULTS: Although there were statistically significant differences between treatments within the earlier part of the administration period, by hour 6 the difference in extent of sensory deficit to cold failed to reach statistical significance along the axillary line (mean = 0.9 cm; SD = 6.8; 95% confidence interval -2.0 to 3.8; P = .515) and transverse line (mean = 2.5 cm; SD = 10.1; 95% confidence interval -1.8 to 6.8; P = .244). Although the difference between treatments was statistically significant at various early time points for the horizontal, vertical, and estimated area measurements of both cold and mechanical pressure sensory deficits, no comparison remained statistically significant by hour 6. CONCLUSIONS: No evidence was found in this study involving healthy volunteers to support the hypothesis that changing the local anesthetic administration technique (continuous basal versus hourly bolus) when using ropivacaine 0.2% and TAP catheters at 8 mL/h and 24 mL every 3 hours significantly influences the cutaneous effects after 6 hours of administration. Additional research is required to determine whether changing variables (eg, local anesthetic concentration, basal infusion rate, bolus dose volume, and/or interval) would provide different results.


Assuntos
Músculos Abdominais , Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Temperatura Baixa/efeitos adversos , Bombas de Infusão , Bloqueio Nervoso/métodos , Músculos Abdominais/efeitos dos fármacos , Amidas/administração & dosagem , Estudos Cross-Over , Método Duplo-Cego , Sistemas de Liberação de Medicamentos/métodos , Feminino , Voluntários Saudáveis , Humanos , Masculino , Medição da Dor/efeitos dos fármacos , Medição da Dor/métodos , Ropivacaina
17.
J Clin Anesth ; 33: 408-12, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27555201

RESUMO

We describe a novel technique of real-time ultrasound-guided superior laryngeal nerve and translaryngeal blocks in 4 patients with anticipated difficult airways. All patients had altered neck anatomy, and 1 had a prior unsuccessful awake fiberoptic bronchoscopic intubation. For block performance, an 11-mm broadband curved array transducer with a scanning frequency between 8 and 5 MHz (Sonosite, Bothell, WA) was used for anatomical structure identification, needle guidance toward each superior laryngeal nerve and through the cricothyroid membrane, and deposition of local anesthetic in the appropriate location. This was followed by successful awake fiberoptic bronchoscopic endotracheal intubation in all cases.


Assuntos
Anestesia por Inalação/instrumentação , Intubação Intratraqueal/métodos , Laringe/diagnóstico por imagem , Bloqueio Nervoso/métodos , Ultrassonografia de Intervenção/métodos , Idoso , Obstrução das Vias Respiratórias , Anestésicos Locais/administração & dosagem , Broncoscopia , Humanos , Nervos Laríngeos , Laringoscopia , Lidocaína/administração & dosagem , Masculino , Pessoa de Meia-Idade , Glândula Tireoide/diagnóstico por imagem , Transdutores
18.
Anesth Analg ; 122(5): 1689-95, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26962712

RESUMO

BACKGROUND: Multiple studies have demonstrated that, for single-injection popliteal sciatic nerve blocks, block characteristics are dependent upon local anesthetic injection relative to the sciatic nerve bifurcation. In contrast, this relation remains unexamined for continuous popliteal sciatic nerve blocks. We, therefore, tested the hypothesis that postoperative analgesia is improved with the perineural catheter tip at the level of the bifurcation compared with 5 cm proximal to the bifurcation. METHODS: Preoperatively, subjects having moderately painful foot or ankle surgery were randomly assigned to receive an ultrasound-guided subepimyseal perineural catheter inserted either at or 5 cm proximal to the sciatic nerve bifurcation. Subjects received a single injection of mepivacaine 1.5% either via the insertion needle preoperatively or the perineural catheter postoperatively, followed by an infusion of ropivacaine 0.2% (6 mL/h basal, 4 mL bolus, and 30-min lockout) for the study duration. The primary end point was the average pain measured on a numeric rating scale (0-10) in the 3 hours before a data collection telephone call the morning after surgery. RESULTS: The average numeric rating scale of subjects with a catheter inserted at the sciatic nerve bifurcation (n = 64) was a median (10th, 25th to 75th, and 90th quartiles) of 3.0 (0.0, 2.4-5.0, and 7.0) vs 2.0 (0.0, 1.0-4.0, and 5.0) for subjects with a catheter inserted proximal to the bifurcation (n = 64; P = 0.008). Similarly, maximum pain scores were greater in the group at the bifurcation: 6.0 (3.0, 4.4-8.0, and 9.0) vs 5.0 (0.0, 3.0-8.0, and 10.0) (P = 0.019). Differences between the groups for catheter insertion time, opioid rescue dose, degree of numbness in the foot/toes, catheter dislodgement, and fluid leakage did not reach statistical significance. CONCLUSIONS: For continuous popliteal sciatic nerve blocks, a catheter inserted 5 cm proximal to the sciatic nerve bifurcation provides superior postoperative analgesia in subjects having moderately painful foot or ankle surgery compared with catheters located at the bifurcation. This is in marked contrast with single-injection popliteal sciatic nerve blocks for which benefits are afforded to local anesthetic injection distal, rather than proximal, to the bifurcation.


Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Cateteres , Pé/cirurgia , Bloqueio Nervoso/instrumentação , Procedimentos Ortopédicos , Dor Pós-Operatória/prevenção & controle , Nervo Isquiático/efeitos dos fármacos , Adulto , Amidas/efeitos adversos , Anestésicos Locais/efeitos adversos , California , Feminino , Pé/inervação , Humanos , Masculino , Mepivacaína/administração & dosagem , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/métodos , Procedimentos Ortopédicos/efeitos adversos , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Estudos Prospectivos , Ropivacaina , Nervo Isquiático/diagnóstico por imagem , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção
19.
Anesth Analg ; 122(5): 1681-8, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26863502

RESUMO

BACKGROUND: It remains unknown whether continuous or scheduled intermittent bolus local anesthetic administration is preferable for adductor canal perineural catheters. Therefore, we tested the hypothesis that scheduled bolus administration is superior or noninferior to a continuous infusion on cutaneous knee sensation in volunteers. METHODS: Bilateral adductor canal catheters were inserted in 24 volunteers followed by ropivacaine 0.2% administration for 8 hours. One limb of each subject was assigned randomly to a continuous infusion (8 mL/h) or automated hourly boluses (8 mL/bolus), with the alternate treatment in the contralateral limb. The primary end point was the tolerance to electrical current applied through cutaneous electrodes in the distribution of the anterior branch of the medial femoral cutaneous nerve after 8 hours (noninferiority delta: -10 mA). Secondary end points included tolerance of electrical current and quadriceps femoris maximum voluntary isometric contraction strength at baseline, hourly for 14 hours, and again after 22 hours. RESULTS: The 2 administration techniques provided equivalent cutaneous analgesia at 8 hours because noninferiority was found in both directions, with estimated difference on tolerance to cutaneous current of -0.6 mA (95% confidence interval, -5.4 to 4.3). Equivalence also was found on all but 2 secondary time points. CONCLUSIONS: No evidence was found to support the hypothesis that changing the local anesthetic administration technique (continuous basal versus hourly bolus) when using an adductor canal perineural catheter at 8 mL/h decreases cutaneous sensation in the distribution of the anterior branch of the medial femoral cutaneous nerve.


Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Nervo Femoral/efeitos dos fármacos , Contração Isométrica/efeitos dos fármacos , Força Muscular/efeitos dos fármacos , Bloqueio Nervoso/métodos , Limiar da Dor/efeitos dos fármacos , Músculo Quadríceps/inervação , Pele/inervação , Adulto , Automação , California , Cateteres , Método Duplo-Cego , Esquema de Medicação , Feminino , Voluntários Saudáveis , Humanos , Bombas de Infusão , Infusões Parenterais , Joelho , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/instrumentação , Medição da Dor , Estudos Prospectivos , Ropivacaina , Fatores de Tempo , Estimulação Elétrica Nervosa Transcutânea , Adulto Jovem
20.
Reg Anesth Pain Med ; 40(5): 559-67, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26115189

RESUMO

BACKGROUND: We tested the hypothesis that, following unicompartment knee arthroplasty, a continuous adductor canal block decreases the time to reach 4 discharge criteria compared with a continuous femoral nerve block. METHODS: Subjects were randomized to either an adductor canal or femoral perineural catheter (2-day ropivacaine 0.2% infusion) in an unmasked fashion. The primary outcome was the time to attain 4 discharge criteria: (1) adequate analgesia; (2) intravenous opioid independence; (3) ability to independently stand, walk 3 m, return, and sit down; and (4) ambulate 30 m. RESULTS: Subjects with an adductor canal catheter (n = 15) reached all 4 criteria in a median of 35 hours (interquartile range, 24-43 hours), compared with 40 hours (interquartile range, 27-69 hours) for those with a femoral catheter (n = 15; Wilcoxon rank sum test: P = 0.46; log-rank test: P = 0.16). However, the percentages of subjects (adductor canal: femoral) who reached the 2 mobilization criteria were 27%:0% on postoperative day (POD) 0, 93%:53% on POD 1, and 100%:73% on POD 2. Of adductor canal subjects, 100% were discharge ready by POD 2, compared with only 73% of femoral subjects (P < 0.001). CONCLUSIONS: Compared with a continuous femoral nerve block, a continuous adductor canal block did not appreciably decrease the median number of hours to overall discharge readiness, yet did decrease the number of discrete days until discharge readiness. These results are applicable to only unicompartment knee arthroplasty and must be considered preliminary because of the limited sample size of this pilot study.


Assuntos
Artroplastia do Joelho/tendências , Bloqueio Nervoso Autônomo/tendências , Nervo Femoral , Dor Pós-Operatória/prevenção & controle , Alta do Paciente/tendências , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/efeitos adversos , Bloqueio Nervoso Autônomo/efeitos adversos , Bloqueio Nervoso Autônomo/métodos , Feminino , Nervo Femoral/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Medição da Dor/tendências , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Alta do Paciente/normas , Projetos Piloto , Estudos Prospectivos , Resultado do Tratamento
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