Peripheral Nerve Block to Treat Pain Caused by Daboia palaestinae Envenomation.

Snakebite pain can be challenging to control. We describe our experience managing intolerable pain after conventional treatment failed. A 35-year-old man, presented after a viper snakebite, suffering from intolerable pain in the affected extremity. He had no significant past medical history. All attempts to control the pain conventionally were unsuccessful. Treatment with a supraclavicular nerve block resulted in immediate relief. After the block receded, only a dull pain remained, which later disappeared without recurrence. This experience illustrates the need for personalized pain treatment to avoid subsequent complications.

Evaluating the Clinical Utility of Brachial Plexus Block for Reducing Opioid Exposure in Pediatric Elbow Fracture Surgery: A Retrospective Cohort Study.

Background and Objectives: Reducing opioid exposure in common pediatric surgeries is of paramount importance. This study aimed to assess the efficacy of regional nerve blocks in reducing opioid exposure while preserving high success rates. Materials and Methods: We conducted a retrospective matched cohort study (1:1) including patients with elbow fractures < 12 years old who underwent treatment with percutaneous pinning. Patients were divided into general-anesthesia (GA) and GA-followed-by-supraclavicular-brachial-plexus-block (GA-SCB) groups. The primary outcome was the number of patients administered postoperative rescue opioids. The secondary outcomes included intraoperative and postoperative opioid administration, the time to first request for rescue analgesia, pain scores, block success rate, block performing time, and block-related complications. Results: In a total of 478 patients, 363 underwent percutaneous pinning, and 86 were cohort-matched (GA: n = 43, GA-SCB: n = 43). On the first postoperative day, 34 (79.0%) patients in the GA group were administered postoperative rescue opioids, compared with 12 (27.9%) in the GA-SCB group (p < 0.001). All the patients in the GA-SCB group were opioid-free during the intraoperative period. No SCB-associated complications were observed. Total opioid consumption was significantly lower in the GA-SCB group than in the GA group until the first postoperative day (GA vs. GA-SCB, 3.2 ± 3.0 mg vs. 0.9 ± 1.8 mg, p < 0.001). Conclusions: SCB application in pediatric patients who underwent elbow fracture surgery significantly reduced opioid exposure and had a high success rate when performed using ultrasound guidance by an expert. Furthermore, the complication risk and surgical delay were minimal.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

Efficacy and safety of ketamine as an adjuvant to regional anesthesia: A systematic review and meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. DESIGN: A Systematic review and meta-analysis of randomized controlled trials. SETTING: The major dates were obtained in the operating room and the postoperative recovery ward. PATIENTS: A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion. INTERVENTIONS: After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block. MEASUREMENT: The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system. MAIN RESULT: Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I2 = 57%). CONCLUSION: This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.

Comparison of the incidence of inadvertent perioperative hypothermia between general anesthesia and interscalene brachial plexus block in shoulder arthroscopy: A randomized prospective study.

INTRODUCTION: Inadvertent perioperative hypothermia (IPH), defined as core body temperature below 36°C, is associated with various complications. Shoulder arthroscopy is a risk factor of IPH. This study aimed to compare the incidence of IPH between general anesthesia (GA) and interscalene brachial plexus block (ISBPB) for shoulder arthroscopy. METHOD: Patients scheduled for shoulder arthroscopy were prospectively enrolled and randomly assigned to GA or ISBPB groups. The body temperature of the patients was measured from baseline to the end of anesthesia and in the post-anesthetic care unit to compare the incidence of IPH. RESULTS: Of the 114 patients initially identified, 80 were included in the study (GA = 40, ISBPB = 40). The incidence of IPH differed significantly between the groups, with GA at 52.5% and ISBPB at 30.0% (P = .04). Profound IPH (defined as < 35.0°C) occurred in 2 patients with GA. Upon arrival at the post-anesthesia care unit, the GA group exhibited a significantly lower mean body temperature (35.9 ±â€…0.6°C) than the ISBPB group (36.1 ±â€…0.2°C, P = .04). CONCLUSION: The incidence of IPH in the GA group was higher than that in the ISBPB group during shoulder arthroscopy, suggesting that ISBPB may be a preferable anesthetic technique for reducing risk of IPH in such procedures.

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.

The effect of block side on hemodynamic and respiratory parameters in patients who had interscalene block for upper limb surgery.

OBJECTIVE: The administration of interscalene block (ISB) may lead to several hemodynamic effects, likely due to the diffusion of local anesthetic to nearby structures such as carotid sinus baroreceptors. This study aimed to compare hemodynamic and respiratory changes resulting from right and left-sided ISB. PATIENTS AND METHODS: A retrospective analysis was conducted on adults who had ultrasound-guided ISB for upper limb surgery between January 2020 and December 2021. All patients had ISB with bupivacaine 0.5% and lidocaine 2% mixture following premedication. Demographic data, arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO2) were measured before and after the block at regular intervals. Block characteristics, surgical and post-anesthesia care unit (PACU) durations, intraoperative analgesic requirements, and side effects were analyzed. RESULTS: A total of 94 patients had ISB for upper limb surgery, 54 for the right and 40 for the left-sided surgeries. Patients' data were analyzed in two groups according to the block side. Increased arterial blood pressure was observed in both groups after the block compared to the control values. Systolic arterial pressure from 10 to 30 minutes, diastolic arterial pressure at the 25th minute, and mean arterial pressure at the 15th, 20th, and 25th minutes were significantly higher on the right-sided blocks. Heart rate, SpO2, analgesic requirements, block characteristics, and PACU durations did not differ between the groups. CONCLUSIONS: Ultrasound-guided ISB-applied patients demonstrated increased blood pressure compared to control values. This increase, without concurrent changes in heart rate, was more pronounced in right-sided ISB. These findings indicate that careful hemodynamic monitoring is necessary whenever hypertension should be avoided for the patients.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Convolutional neural network for brachial plexus segmentation at the interscalene level.

BACKGROUND: Regional anesthesia with ultrasound-guided brachial plexus block is widely used for patients undergoing shoulder and upper limb surgery, but needle misplacement can result in complications. The purpose of this study was to develop and validate a convolutional neural network (CNN) model for segmentation of the brachial plexus at the interscalene level. METHODS: This prospective study included patients who underwent ultrasound-guided brachial plexus block in the Anesthesiology Department of Beijing Jishuitan Hospital between October 2019 and June 2022. A Unet semantic segmentation model was developed to train the CNN to identify the brachial plexus features in the ultrasound images. The degree of overlap between the predicted segmentation and ground truth segmentation (manually drawn by experienced clinicians) was evaluated by calculation of the Dice index and Jaccard index. RESULTS: The final analysis included 502 images from 127 patients aged 41 ± 14 years-old (72 men, 56.7%). The mean Dice index was 0.748 ± 0.190, which was extremely close to the threshold level of 0.75 for good overlap between the predicted and ground truth segregations. The Jaccard index was 0.630 ± 0.213, which exceeded the threshold value of 0.5 for a good overlap. CONCLUSION: The CNN performed well at segregating the brachial plexus at the interscalene level. Further development could allow the CNN to be used to facilitate real-time identification of the brachial plexus during interscalene block administration. CLINICAL TRIAL REGISTRATION: The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055591), the site url is https://www.chictr.org.cn/ . The date of trial registration and patient enrollment is 14/01/2022.

Optimal analgesic regimen for total shoulder arthroplasty: a randomized controlled trial and network meta-analysis.

OBJECTIVE: Clinical approaches to analgesia following total shoulder arthroplasty include liposomal bupivacaine, local infiltration analgesia, single-shot interscalene block, and continuous interscalene block. However, the best method remains contentious. This study conducts a network meta-analysis comparing these four methods, aiming to identify the most effective analgesic approach. METHODS: Randomized controlled trials on analgesic regimens for total shoulder arthroplasty were identified through searches of PUBMED, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Scopus databases, covering their inception through November 2023. Network meta-analysis was performed using STATA 15.1, and the Cochrane Handbook version 5.1.0 risk of bias tool was employed for quality assessment of the literature. RESULTS: Twelve randomized controlled trials were included, comprising 1537 patients undergoing total shoulder arthroplasty. The interventions compared were ssISB, cISB, LIA, and LB. Regarding the quality of the literature, four studies were deemed low risk, one high risk, and seven moderate risk. The network meta-analysis revealed that in terms of VAS scores in the PACU, the ssISB group was the most effective, followed by cISB and LB, with LIA being the least effective. This pattern continued in VAS scores on the first and second postoperative days. Regarding morphine consumption, the cISB group showed the most significant reduction in the PACU and on the first postoperative day, while the LIA group performed best in total postoperative morphine consumption. The shortest average hospital stay was noted in the cISB group. CONCLUSION: The ssISB method excels in controlling early postoperative pain, particularly during the PACU stage and early postoperative period. Additionally, the cISB method is notable for reducing postoperative morphine consumption and shortening average hospital stays. While the LIA method ranks first in reducing total morphine consumption, it is weaker in pain control. The LB method is underwhelming across most assessment parameters. These findings underscore the importance of selecting appropriate analgesic strategies for different postoperative recovery phases and provide valuable insights for clinicians to optimize postoperative pain management. Furthermore, they suggest a need for future research to explore the specific application and effectiveness of these methods in varying clinical contexts.

Comparison of shoulder anterior capsular block and interscalene brachial plexus block for shoulder arthroscopy: a preliminary analysis.

BACKGROUND: This study aims to reveal the perioperative analgesic efficacy of a new technique, anterior capsular shoulder block, in treating pain after shoulder arthroscopy compared to the interscalene brachial plexus block. METHODS: The study design is randomized, prospective, interventional, standardized and double-blind in the setting of orthopedic operating room and orthopedic postoperative ward. Forty patients between 18-90 years of age and with American Society of Anesthesiologists Physical Status classification I to III who received arthroscopic cuff repair surgery were randomized into two (1:1 distribution; N.=20) groups. The interventions were interscalene brachial plexus block for Group A and shoulder anterior capsular block for Group B. Primary measurements were pain scores within 48 hours. Secondarily total analgesia requirement, intraoperative heart rate and blood pressure, arthroscopic image quality were evaluated. RESULTS: Pain scores within postoperative 48 hours were similar between SHAC and ISB groups with no significant difference (P>0.05). Total analgesia requirement, intraoperative and postoperative rescue analgesia, was also similar with no significance (P>0.05). CONCLUSIONS: This study demonstrated that the anterior capsular shoulder block is an effective alternative with similar results to the interscalene brachial plexus block for managing pain after shoulder arthroscopy.

Application and Research Progress of Ultrasound-Guided Brachial Plexus Block Through Costoclavicular Space Approach in Upper Limb Surgery.

Objective: Exploring newer approaches to brachial plexus block is crucial for improving surgical outcomes and patient comfort. This study aims to review the application and research progress of ultrasound-guided brachial plexus block via the costoclavicular space approach in upper limb surgery. Methods: This study provides a comprehensive review of existing literature, studies, and clinical cases related to the costoclavicular approach. The advantages and disadvantages of conventional approaches for brachial plexus block, including the intermuscular groove method, supraclavicular method, and axillary approach, are discussed. The anatomical characteristics of the costoclavicular space are examined, and the methods of brachial plexus nerve block using ultrasound-guided costoclavicular space approach are described. It holds great promise for enhancing patient care and increasing the overall success rate of surgical procedures. Results: The costoclavicular space approach for brachial plexus block offers several advantages, including stable anatomical structure, low nerve variation rate, and clear visualization of each nerve bundle under ultrasound imaging. Compared to traditional approaches, ultrasound-guided brachial plexus block via the costoclavicular space approach has a high success rate, rapid onset of anesthesia, and high safety. Conclusion: Ultrasound-guided brachial plexus block via the costoclavicular space approach is effective and safe in upper limb surgery. It provides good anesthesia and postoperative analgesia, making it a valuable technique for various upper limb surgeries. The potential clinical significance of our findings lies in the possibility that ultrasound-guided costoclavicular space approach, with its enhanced precision and patient outcomes, could play a pivotal role in improving upper limb surgical procedures.

Eighth Cervical Nerve Root Block During Interscalene Brachial Plexus Block Decreases Pain Caused by Posterior Portal Placement but Increases Horner Syndrome in Patients Undergoing Arthroscopic Shoulder Surgery: A Randomized Controlled Trial.

PURPOSE: To compare the intensity of pain on posterior portal placement between a C5-C7 root block (conventional interscalene brachial plexus block [ISBPB]) and a C5-C8 root block in patients undergoing arthroscopic shoulder surgery. METHODS: In this prospective, single-blinded, parallel-group randomized controlled trial, patients were randomized to receive either a C5-C7 root block (C5-C7 group, n = 37) or a C5-C8 root block (C5-C8 group, n = 36) with 25 mL of 0.75% ropivacaine. The primary outcome was the pain intensity on posterior portal placement, which was graded as 0 (no pain), 1 (mild pain), or 2 (severe pain). The secondary outcomes were the bilateral pupil diameters measured 30 minutes after ISBPB placement; the incidence of Horner syndrome, defined as a difference in pupil diameter (ipsilateral - contralateral) of less than -0.5 mm; the onset of postoperative pain; and the postoperative numerical rating pain score, where 0 and 10 represent no pain and the worst pain imaginable, respectively. RESULTS: Fewer patients reported mild or severe pain on posterior portal placement in the C5-C8 group than in the C5-C7 group (9 of 36 [25.0%] vs 24 of 37 [64.9%], P = .003). Less pain on posterior portal placement was reported in the C5-C8 group than in the C5-C7 group (median [interquartile range], 0 [0-0.75] vs 1 [0-1]; median difference [95% confidence interval], 1 [0-1]; P = .001). The incidence of Horner syndrome was higher in the C5-C8 group than in the C5-C7 group (33 of 36 [91.7%] vs 22 of 37 [59.5%], P = .001). No significant differences in postoperative numerical rating pain scores and onset of postoperative pain were found between the 2 groups. CONCLUSIONS: A C5-C8 root block during an ISBPB reduces the pain intensity on posterior portal placement. However, it increases the incidence of Horner syndrome with no improvement in postoperative pain compared with the conventional ISBPB (C5-C7 root block). LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Equal mixture of 2% lidocaine with adrenaline and 0.5% bupivacaine 20 mL provided faster onset of complete conduction blockade during ultrasound-guided supraclavicular brachial plexus block than 20 mL of 0.5% bupivacaine alone: a randomized double-blinded clinical trial.

INTRODUCTION: Recent evidence has questioned the advantage of local anesthetic (LA) combinations. This study tested the hypothesis that mixing rapid-onset (lidocaine) and long-duration (bupivacaine) LA would provide faster onset of complete conduction blockade (CCB) compared with bupivacaine alone and longer duration of analgesia compared with lidocaine alone during low-volume (20 mL) ultrasound-guided (USG) supraclavicular brachial plexus block (SCBPB). METHODS: Sixty-three patients receiving USG-SCBPB were randomly allocated into: group L: 20 mL 2% lidocaine with epinephrine 1:200 000; group B: 20 mL 0.5% bupivacaine; group LB: 20 mL of equi-volume mixture of both drugs. Sensory and motor blockade was recorded on a three point sensory and motor assessment scale at 10 min intervals for up to 40 min and the total composite score (TCS) at each time point was determined. The duration of analgesia was also noted. RESULTS: The mean time to CCB of group LB (16±7 min) was comparable (p>0.05) with group L (14±6 min) and group B (21±8 min) in patients who were attained CCB. However, the proportion of patients attaining complete conduction block (TCS=16/16) was significantly lower (p=0.0001) in group B (48%) when compared with group L (95%) and group LB (95%) at the end of 40 min. The median (IQR) duration of postoperative analgesia was longest in group B; 12.2 (12-14.5) hours, followed by group LB 8.3 (7-11) hours and 4 (2.7-4.5) hours in group L. CONCLUSION: At 20 mL LA volume, equal mixture of lidocaine and bupivacaine provided significantly faster onset of CCB compared with bupivacaine alone and longer duration of postoperative analgesia compared with lidocaine alone but shorter than bupivacaine alone during low-volume USG-SCBPB. TRIAL REGISTRATION NUMBER: CTRI/2020/11/029359.