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1.
Medicine (Baltimore) ; 99(10): e19240, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32150060

RESUMO

BACKGROUND: With the improvement of anesthesia and surgical techniques, supraglottic device with assist ventilation under general anesthesia (GA) combined with nerve block is gradually applied to video-assisted thoracoscopic surgery. However, the safety of assist ventilation has not been fully confirmed, and a large number of samples should be studied in clinical exploration. METHODS: The subjects included 120 patients, undergoing elective thoracoscopic GA, with American Society of Anesthesiologists (ASA) physical status I or II, were randomly divided into 3 groups, 40 cases in each group. Group T: received double-lumen bronchial intubation, Group I: received intercostal nerve block using a supraglottic device, Group P: received paravertebral nerve block using a supraglottic device. Mean arterial pressure, heart rate, saturation of pulse oximetry and surgical field satisfaction, general anesthetic dosage and recovery time were recorded before induction of GA (T0), at the start of the surgical procedure (T1), 15 minutes later (T2), 30 minutes later (T3), and before the end of the surgical procedure (T4). Static and dynamic pain rating (NRS) and Ramsay sedation score were recorded 2 hours after surgery (T5), 12 hours after surgery (T6), 24 hours after surgery (T7), time to get out of bed, hospitalization time and cost, patient satisfaction and adverse reactions. RESULTS: There was no significant difference with the surgical visual field of the 3 groups (P > .05). The MAP, HR and SpO2 of the 3 groups were decreased from T2 to T3 compared with T0(P < .05). Compared with group T: the total dosage of GA was reduced in group I and group P, the recovery time was shorter, the time to get out of bed was earlier (P < .05), the hospitalization time was shortened, the hospitalization cost was lower, and the patient satisfaction was higher (P < .05). The static and dynamic NRS scores were lower from T5 to T7 (P < .05). Ramsay sedation scores were higher (P < .05), and the incidence of adverse reactions was lower (P < .05). Comparison between group I and group P: Dynamic NRS score of group P was lower from T6 to T7 (P < .05). CONCLUSION: Supraglottic device with assist ventilation under general anesthesia combined with nerve block in uniportal video-assisted thoracoscopic surgery is safe and feasible.


Assuntos
Anestesia Geral/instrumentação , Bloqueio Nervoso/instrumentação , Respiração Artificial , Cirurgia Torácica Vídeoassistida , Adulto , Período de Recuperação da Anestesia , Anestesia Geral/efeitos adversos , Anestésicos Gerais/administração & dosagem , Pressão Sanguínea , Procedimentos Cirúrgicos Eletivos , Estudos de Viabilidade , Feminino , Frequência Cardíaca , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Oximetria
2.
Anaesthesia ; 75(4): 499-508, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31984478

RESUMO

Interscalene brachial plexus block provides analgesia for shoulder surgery but is associated with hemidiaphragmatic paralysis. Before considering a combined suprascapular and axillary nerve block as an alternative to interscalene brachial plexus block, evaluation of the incidence of diaphragmatic dysfunction according to the approach to the suprascapular nerve is necessary. We randomly allocated 84 patients undergoing arthroscopic shoulder surgery to an anterior or a posterior approach to the suprascapular nerve block combined with an axillary nerve block using 10 ml ropivacaine 0.375% for each nerve. The primary outcome was the incidence of hemidiaphragmatic paralysis diagnosed by ultrasound. Secondary outcomes included: characterisation of the hemidiaphragmatic paralysis over time; numeric rating scale pain scores; oral morphine equivalent consumption; and patient satisfaction. The incidence of hemidiaphragmatic paralysis was 40% (n = 17) vs. 2% (n = 1) in the anterior and posterior groups, respectively (p < 0.001). In one third of patients with hemidiaphragmatic paralysis, it persisted beyond the eighth hour. The median (interquartile range [range]) oral morphine equivalent consumption was significantly higher in the posterior approach when compared with the anterior approach, whether in the recovery area (20 [5-31 (0-60)] mg vs. 7.5 [0-14 (0-52)] mg, respectively; p = 0.004) or during the first 24 h (82 [61-127 (12-360) mg] vs. 58 [30-86 (0-160)] mg, respectively; p = 0.01). Patient satisfaction was comparable between groups (p = 0.6). Compared with the anterior approach, diaphragmatic function is best preserved with the posterior needle approach to the suprascapular nerve block.


Assuntos
Bloqueio Nervoso/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Paralisia Respiratória/induzido quimicamente , Ombro/inervação , Ombro/cirurgia , Ultrassonografia de Intervenção/métodos , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Resultado do Tratamento
3.
Br J Anaesth ; 124(1): 92-100, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31711605

RESUMO

BACKGROUND: Intravenous dexamethasone is thought to prolong the duration of peripheral nerve block, but the dose-response relationship remains unclear. The aim of this volunteer study was to evaluate the dose-response effect of i.v. dexamethasone on the prolongation of median nerve block. METHODS: In a double-blind, randomised controlled study, 18 volunteer subjects received two median nerve blocks separated by a washout period. One block was conducted alongside an infusion of saline and the other alongside i.v. dexamethasone 2, 4, or 8 mg. The primary outcome was time to return of normal pinprick sensation. Secondary outcomes included thermal quantitative sensory testing (QST) for the time to return of cold detection threshold (CDT), warm detection threshold (WDT), cold pain threshold (CPT), heat pain threshold (HPT), area under QST curves, grip strength, and the incidence of adverse effects. RESULTS: The primary outcome, time to recovery of pinprick sensation, was similar between volunteers receiving saline or i.v. dexamethasone, regardless of dose (P=0.99). The time to recovery of QST milestones was similar between groups, although area under QST curves indicated prolongation of CDT (0 vs 8 mg, P=0.002) and WDT (0 vs 2 mg, P=0.008; 0 vs 4 mg, P=0.001; 0 vs 8 mg, P<0.001). There was no difference in motor recovery or adverse effects. CONCLUSIONS: Intravenous dexamethasone failed to significantly prolong the duration of pinprick anaesthesia regardless of dose. However, area under QST curve analysis indicated a dose-independent prolongation of CDT and WDT, the clinical significance of which is unclear. CLINICAL TRIAL REGISTRATION: NCT02864602 (clinicaltrials.gov).


Assuntos
Adjuvantes Anestésicos , Dexametasona , Bloqueio Nervoso/métodos , Nervos Periféricos , Adjuvantes Anestésicos/administração & dosagem , Adjuvantes Anestésicos/efeitos adversos , Administração Intravenosa , Adulto , Estudos Cross-Over , Dexametasona/administração & dosagem , Dexametasona/efeitos adversos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Força da Mão , Voluntários Saudáveis , Humanos , Masculino , Nervo Mediano , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Limiar da Dor/efeitos dos fármacos , Sensação/efeitos dos fármacos , Sensação Térmica/efeitos dos fármacos , Adulto Jovem
5.
Medicine (Baltimore) ; 98(41): e17542, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593133

RESUMO

BACKGROUND: Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia are 2 common methods of maintaining analgesia after cesarean section. In recent years, transversus abdominis plane block (TAPB) has been gradually applied clinically to reduce opioid analgesics and has achieved good results. Therefore, we performed this study to compare the efficacy and side effects of TAPB and PCIA in analgesia after cesarean section. METHODS: One hundred patients who underwent cesarean section were randomly classified into 2 groups. Following surgery, one group underwent ultrasound-guided TAPB and the other group underwent PCIA. Pain intensity according to the visual analog scale (VAS; 0 for no pain and 10 for severe intolerable pain) was assessed at 2, 4, 6, 8, 12, and 24-hour postsurgery in both groups. The postoperative complication rate and patient satisfaction were also measured. RESULTS: No significant differences were found in the VAS scores between the groups (P > .05). However, the incidence of postoperative complications in the TAPB group was significantly lower than that in the PCIA group (P < .05). Furthermore, patient satisfaction in the TAPB group was significantly higher than that in the PCIA group (P < .05). CONCLUSION: This study demonstrated that ultrasound-guided TAPB can achieve the same analgesic effect as PCIA after cesarean section but with even higher patient satisfaction.


Assuntos
Músculos Abdominais/inervação , Analgesia Controlada pelo Paciente/métodos , Cesárea/efeitos adversos , Bloqueio Nervoso/métodos , Ultrassonografia de Intervenção/métodos , Músculos Abdominais/diagnóstico por imagem , Músculos Abdominais/efeitos dos fármacos , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Cesárea/métodos , Feminino , Humanos , Incidência , Bloqueio Nervoso/efeitos adversos , Satisfação do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Gravidez , Qualidade de Vida , Escala Visual Analógica
6.
BMC Musculoskelet Disord ; 20(1): 441, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601208

RESUMO

BACKGROUND: Continuous popliteal sciatic nerve block (CPSNB) has been performed in outpatient foot and ankle surgery as a regional anesthesia method to relieve postoperative pain. Its efficacy as well as safety is yet to be established. There are two purposes of this study: (1) to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption; (2) to assess the safety of CPSNB. METHODS: We performed a comprehensive literature review on Web of Science, the Cochrane Library, PubMed and Embase and only included randomized controlled trials (RCTs). Five RCTs that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group were included. The primary outcome parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 h. The secondary outcome parameters were amount of oral analgesics consumed, overall patient satisfaction and need of admission after surgery. A sensitivity analysis was performed to explore the consistency of the results. RESULTS: In comparison with the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 h (p < 0.05). There were no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, with drug leakage being the most common complication (N = 26 of 187, 13.9%). CONCLUSION: CPSNB is an effective method in pain management for outpatient foot and ankle surgery. Both methods appear to be safe as none of the patients experienced neuropathic symptoms or infection. Further studies with larger sample size are needed to compare the risk of major complications between the two methods. LEVEL OF EVIDENCE: I; meta-analysis.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/métodos , Procedimentos Ortopédicos/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Nervo Isquiático/efeitos dos fármacos , Anestésicos Locais/efeitos adversos , Tornozelo/cirurgia , Esquema de Medicação , Pé/cirurgia , Humanos , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Resultado do Tratamento
8.
Niger J Clin Pract ; 22(9): 1301-1303, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31489871

RESUMO

Neuropathic pain responds poorly to common analgesics that effectively control nociceptive pain because its pathophysiology is different and it is usually associated with co-morbidities such as sleep disturbance, depression and anxiety. Patients with this chronic pain are sometimes left with neurolysis as the last resort. A 65-year-old male multiply-injured retiree presented with disabling pain following traumatic brachial plexus injury sustained from road traffic accident 5 years earlier. Other injuries resolved with therapy except the chronic severe burning and electrifying pain (VAS score 9) in the paralyzed left upper limb associated with allodynia and insomnia which was unresponsive to conventional analgesics. PainDETECT score was 29. A test supraclavicular block with 0.25% Bupivacaine was done, followed by chemical neurolysis one month later. He was placed on oral Gabapentin. The pain score a week post injection was 3 and has remained same 18 months post injection. Patient's level of satisfaction on 5 point Likert scale was 5. Chronic neuropathic pain following traumatic brachial plexus injury could be successfully managed by chemical neurolysis and oral gabapentin.


Assuntos
Analgésicos/administração & dosagem , Neuropatias do Plexo Braquial/complicações , Neuropatias do Plexo Braquial/tratamento farmacológico , Plexo Braquial/lesões , Gabapentina/administração & dosagem , Bloqueio Nervoso/métodos , Neuralgia/tratamento farmacológico , Extremidade Superior/lesões , Adulto , Idoso , Analgésicos/uso terapêutico , Neuropatias do Plexo Braquial/fisiopatologia , Bupivacaína/administração & dosagem , Gabapentina/uso terapêutico , Humanos , Hiperalgesia/etiologia , Masculino , Bloqueio Nervoso/efeitos adversos , Neuralgia/etiologia , Medição da Dor , Sono/efeitos dos fármacos , Distúrbios do Início e da Manutenção do Sono/etiologia , Resultado do Tratamento
9.
Curr Opin Anaesthesiol ; 32(5): 638-642, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31415044

RESUMO

PURPOSE OF REVIEW: Summarize the current thinking concerning the clinically relevant aspects of nerve anatomy and best injection sites for nerve blocks. RECENT FINDINGS: The widespread use of ultrasound in regional anesthesia has changed the practice of regional anesthesia and created new possibilities. Among them is the ability to identify fascial planes, and this has become the basis for a new group of blocks, the fascial plane blocks. In this kind of blocks, the target for injection is the plane itself and not a nerve in particular. transversus abdominis plane, pectoralis muscles, erector spinae plane blocks are some examples of fascial blocks. Because injecting into a fascial plane is not controversial, these blocks are not included in our discussion of optimal placement of the needle.To determine optimal needle placement, it is important to have a clear definition of what constitutes intraneural. Although, there is almost universal agreement that the violation of the epineurium defines the intraneural concept, the literature include several studies where this assessment is erroneous.Although intentional intraneural injection is still considered objectionable, some literature suggests that injecting intraneurally, especially if extrafascicular, may be benign. This evidence is limited and anecdotal. SUMMARY: It is necessary to have a better understanding of what intraneural injection is when dealing with any type of nerve blocks, be that single nerve, plexuses, or the sciatic nerve. Perineural injections provide successful anesthesia without putting the nerve integrity at risk. That practice is supported by years of experience and common sense. Currently, there is no evidence to support any kind of intraneural injections, intrafascicular or extrafascicular.


Assuntos
Agulhas/efeitos adversos , Bloqueio Nervoso/métodos , Traumatismos dos Nervos Periféricos/prevenção & controle , Nervos Periféricos/anatomia & histologia , Humanos , Injeções/efeitos adversos , Injeções/instrumentação , Injeções/métodos , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/instrumentação , Traumatismos dos Nervos Periféricos/etiologia , Nervos Periféricos/diagnóstico por imagem , Ultrassonografia de Intervenção
10.
Trials ; 20(1): 391, 2019 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-31266529

RESUMO

BACKGROUND: Transversus abdominis plane (TAP) block and wound infiltration (WI) are common locoregional anesthesia techniques for pain management in patients undergoing colorectal laparoscopic surgery. Comparative data between these two practices are conflicting, and a clear benefit of TAP block over WI is still debated. The main purpose of this study is to determine the efficacy in pain control of WI compared with WI plus laparoscopic TAP block (L-TAP) in cases of laparoscopic colorectal resection. Secondary aims are to evaluate other short-term results directly related to pain management: the need for rescue analgesic drugs, the incidence of postoperative nausea and vomiting, the resumption of gut functions, and the length of hospital stay. METHODS/DESIGN: This is a prospective, randomized, controlled, two-arm, multicenter, single-blind study evaluating the efficacy of postoperative analgesic management of WI versus WI plus L-TAP in the context of laparoscopic colorectal surgery. Randomization is at the patient level, and participants are randomized 1:1 to receive either WI alone or WI plus L-TAP. Those eligible for inclusion were patients undergoing laparoscopic resection for colorectal tumor or diverticular disease at the Division of General and Hepatobiliary Surgery, Verona University, Verona, Italy, and at the Colorectal Cancer Center, Kyungpook National University, Daegu, Korea. Fifty-four patients are needed in each group to evidence a difference greater than 1 of 10 according to the numeric rating scale for pain assessment to establish that this difference would matter in practice. DISCUSSION: The demonstration of a noninferiority of WI compared with WI plus L-TAP block would call into question TAP block usefulness in the setting of laparoscopic colorectal surgery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03376048 . Prospectively registered on 15 December 2017.


Assuntos
Músculos Abdominais/inervação , Anestésicos Locais/administração & dosagem , Colectomia/métodos , Neoplasias Colorretais/cirurgia , Doenças Diverticulares/cirurgia , Laparoscopia , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Ropivacaina/administração & dosagem , Adulto , Idoso , Anestésicos Locais/efeitos adversos , Colectomia/efeitos adversos , Estudos de Equivalência como Asunto , Feminino , Humanos , Itália , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , República da Coreia , Ropivacaina/efeitos adversos , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
11.
Best Pract Res Clin Anaesthesiol ; 33(1): 47-56, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31272653

RESUMO

Nerve injury is a relatively rare but devastating complication of peripheral nerve blockade (PNB). Monitoring injection pressure during PNB is one method advocated to prevent injury by detecting needle tip placement in a noncompliant position (intraneural or abutting the epineurium). Animal studies show that gross neural damage and clinical injury are associated with injection pressures exceeding 15-20 psi. In contrast, pressures <15 psi are associated with an extraneural needle tip position and no histologic or clinical injury. Injection pressure monitoring has been shown to prevent injection against the brachial plexus roots or femoral nerve during peripheral nerve block. Multiple methods are available to monitor injection pressure, and most of them are inexpensive and easy to use. Large-scale registry database or pragmatic trials are indicated to show that injection pressure monitoring reduces injury in a patient setting.


Assuntos
Reação no Local da Injeção/patologia , Monitorização Intraoperatória/métodos , Bloqueio Nervoso/efeitos adversos , Traumatismos dos Nervos Periféricos/patologia , Humanos , Reação no Local da Injeção/etiologia , Reação no Local da Injeção/prevenção & controle , Injeções/efeitos adversos , Bloqueio Nervoso/instrumentação , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/prevenção & controle , Pressão/efeitos adversos , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodos
12.
Trials ; 20(1): 441, 2019 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-31315670

RESUMO

BACKGROUND: Spine surgery is associated with considerable postoperative pain and can be challenging to treat. A loco-regional technique suitable for spine surgery should cover the dorsal root of the spinal nerves at the levels where surgery is performed. The erector spinae block is a loco-regional technique with promising results and was recently described at the thoracic level. There are no randomized trials of this technique on a lumbar level. This study tests the hypothesis that the 24-h postoperative morphine consumption is significantly lower in patients undergoing posterior lumbar inter-body fusion surgery with a lumbar erector spinae (LUMBES) block when compared with a sham block. METHODS: This prospective randomized double-blind multicenter study will randomly allocate 80 adult patients undergoing elective posterior lumbar inter-body fusion surgery during general anesthesia to one of two groups as follows: (1) bilateral erector spinae block (20 mL 0.25% levobupivacaine) or (2) bilateral sham block (20 mL NaCl 0.9%). Our primary endpoint is 24-h postoperative morphine consumption. Secondary endpoints include 72-h morphine consumption, intraoperative sufentanil dosage, postoperative pain scores at regular time intervals both at rest and during movement, time to first postoperative mobilization, and the Quality of Recovery 40 survey score. DISCUSSION: The LUMBES trial is a pragmatic clinical study that will provide evidence of whether a bilateral lumbar erector spinae block is effective in reducing 24-h postoperative morphine consumption in patients undergoing lumbar inter-body fusion surgery. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of this technique. TRIAL REGISTRATION: Local ethics committee B300201837508, ClinicalTrials.gov identifier: NCT03825198 . Registered on 31 Jan 2019.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Músculos do Dorso/inervação , Dor nas Costas/prevenção & controle , Levobupivacaína/administração & dosagem , Vértebras Lombares/cirurgia , Morfina/administração & dosagem , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Fusão Vertebral/efeitos adversos , Adolescente , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/efeitos adversos , Dor nas Costas/diagnóstico , Dor nas Costas/etiologia , Dor nas Costas/fisiopatologia , Bélgica , Método Duplo-Cego , Feminino , Humanos , Levobupivacaína/efeitos adversos , Masculino , Pessoa de Meia-Idade , Morfina/efeitos adversos , Estudos Multicêntricos como Assunto , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Ensaios Clínicos Pragmáticos como Assunto , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
13.
J Surg Res ; 244: 15-22, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31279259

RESUMO

BACKGROUND: Intrathecal morphine (ITM) and peripheral nerve blocks are accepted techniques for analgesia after abdominal surgery, but their efficacy has not been evaluated in the context of an enhanced recovery pathway (ERP) in pancreatic surgery. MATERIALS AND METHODS: We retrospectively compared postoperative analgesia (pain scores and opioid requirements) after open or robotic pancreatoduodenectomy or distal pancreatectomy among ERP patients receiving either ITM or transversus abdominis plane/quadratus lumborum (TAP/QL) nerve blocks. RESULTS: We identified 303 ERP patients who underwent pancreatectomy with either ITM (n = 251) or TAP/QL blocks (n = 52). Patient demographics and procedural variables were similar between groups. Few preoperative patient characteristics (preoperative stroke and pain medication intake) differed between the two groups. In an unmatched patient cohort, the median pain score on postoperative day (POD 0) zero was 4.5 (interquartile range [IQR] 2.3-5.8) in ITM patients compared with 5.7 (IQR, 3.4-6.9) in patients who received TAP/QL (P < 0.05). Median opioid consumption in intravenous morphine equivalents on POD 0 was 2.7 mg (IQR, 0-11.7) in ITM patients compared with 8.4 mg (IQR, 2.5-20.8) in TAP/QL patients (P < 0.001). After propensity matching for patient characteristics, pain scores and opioid consumption were significantly (P < 0.05) lower on POD 0 and POD 5 in patients who received ITM. The difference in quality of analgesia between ITM and TAP/QL was also maintained in the pancreaticoduodenectomy and distal pancreatectomy subgroups. Extubation in the operating room was achieved in a higher percentage of patients receiving ITM (92%) compared with those receiving TAP/QL (63%). The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSIONS: ITM was associated with reduced pain scores and opioid requirements compared with peripheral nerve blocks in an ERP for pancreatic surgery.


Assuntos
Analgésicos Opioides/administração & dosagem , Morfina/administração & dosagem , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Pancreatectomia/efeitos adversos , Pancreaticoduodenectomia/efeitos adversos , Músculos Abdominais/inervação , Idoso , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Injeções Espinhais , Masculino , Pessoa de Meia-Idade , Morfina/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Manejo da Dor/estatística & dados numéricos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Pancreatectomia/métodos , Pancreaticoduodenectomia/métodos , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/etiologia , Estudos Retrospectivos , Fatores de Tempo
14.
Pain Physician ; 22(4): 389-400, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31337175

RESUMO

BACKGROUND: Closed malpractice claims can provide insight into low-frequency adverse events in many areas of perioperative and chronic pain care. Over the last decade, there have been changes in surgical and regional anesthetic practice, likely impacting adverse event patterns. Given the wide variability and low frequency of complications associated with peripheral nerve blocks, the study of closed malpractice claims offers an opportunity to examine adverse events, and the patient, technical, and provider factors that led to the claim. Knowledge gained from examination of closed claims has already resulted in multiple improvements in processes of care and patient safety. OBJECTIVES: An investigation of the factors that contributed to medicolegal claims against anesthesia providers related to peripheral nerve blocks. STUDY DESIGN: Retrospective analysis. SETTING: Inpatient and outpatient surgery facilities. METHODS: The Comparative Benchmarking System database is a medical liability database that contains more than 400,000 malpractice claims from more than 400 academic and community-based institutions accounting for over 30% of malpractice claims in the United States. The present investigation reviewed all (n = 113) available closed malpractice claims related to regional anesthesia (RA) in surgical patients closed between 2006 and 2016, and investigated factors that may have contributed to patient injury, including type of nerve block, type of surgery, nerves injured, resulting neurologic deficits, and potential factors contributing to the injury. RESULTS: Our data analyzed 62 claims related to RA and showed that most closed claims were classified as permanent minor injuries. The greatest number of claims were for brachial plexus injuries associated with interscalene blocks performed for shoulder or rotator cuff repairs. Femoral and sciatic nerve blocks with resulting lower extremity injuries were the most common nerve blocks resulting in payment. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the regionalist followed by "Pre-existing Injury/Radiculopathy." Symptom onset from these claims was most likely to be delayed with the leading initial presenting symptom being paresthesia. LIMITATIONS: It is difficult to establish cause-effect relationship, and the small sample size limits the ability to detect clinical differences and associations with specific comorbidities or techniques. There was also limited information related to regional anesthetic techniques and medications used that would have helped explore further relationships between the procedure and cause for litigation. CONCLUSIONS: There remains significant room for risk reduction in regional anesthetic practice. Patterns based on the analysis of closed claims show that interscalene blocks are the most common peripheral nerve block resulting in litigation, even when compared with other blocks involving the brachial plexus. Furthermore, patients with existing nerve injury/radiculopathy may also warrant alternative techniques or greater emphasis during informed consent on the increased risk of injury. As most of the presenting symptoms associated with claims are delayed, an opportunity for improvement in postregional care may be better communication with patients following discharge to discuss their postoperative recovery. KEY WORDS: Regional, pain, anesthesia, complications, closed claims, liability, nerve, block, injury.


Assuntos
Bloqueio Nervoso/efeitos adversos , Complicações Pós-Operatórias , Adulto , Bases de Dados Factuais , Feminino , Humanos , Revisão da Utilização de Seguros , Responsabilidade Legal , Masculino , Imperícia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Estados Unidos
15.
Curr Opin Anaesthesiol ; 32(5): 674-682, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31356362

RESUMO

PURPOSE OF REVIEW: Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery. RECENT FINDINGS: Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking. SUMMARY: New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.


Assuntos
Analgesia/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/terapia , Assistência Perioperatória/métodos , Analgesia/efeitos adversos , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , /prevenção & controle , Dor Pós-Operatória/etiologia , Assistência Perioperatória/efeitos adversos , Resultado do Tratamento
16.
A A Pract ; 13(5): 173-175, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31265445

RESUMO

Neurologic complications following neuraxial anesthesia for cesarean delivery are rare. We present a 33-year-old parturient who developed prolonged lower extremity weakness following a single-shot subarachnoid block for cesarean delivery. After neurologic evaluation, she was diagnosed with bilateral sciatic neuropathies due to prolonged positioning for the anesthetic. We review the incidence of nerve injury associated with neuraxial anesthesia and risk factors for developing peripheral nerve injury in this context. We offer a solution to prevent this complication from occurring.


Assuntos
Bloqueio Nervoso/efeitos adversos , Nervo Isquiático/lesões , Neuropatia Ciática/etiologia , Adulto , Anestesia Obstétrica/efeitos adversos , Cesárea , Feminino , Humanos , Gravidez
17.
Ann Phys Rehabil Med ; 62(4): 252-264, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31202956

RESUMO

INTRODUCTION: Motor nerve blocks with anesthetic drug for local anesthesia are commonly used in physical and rehabilitation medicine (PRM), especially in the field of spasticity. Guidelines in this context are currently lacking. METHOD: Eighteen experts selected on the basis of their recognized experience by the scientific committees of the French PRM (SOFMER) and Anesthesia and Intensive care (SFAR) societies were invited to work and propose guidelines for the use of loco-regional anesthetic drug for motor nerve blocks in PRM setting. Eight issues were addressed: which neural blocks for which indications; drugs and contraindications; medical survey and attitude in case of adverse event; injection and guidance material; patient preparation and pain relief; efficacy assessment; patient information; education of PRM physiatrists. The Medline, Cochrane and Embase databases for the period 1999 to 2018 were consulted and 355 papers analyzed. The drafts were commented then approved by the whole group using electronic vote, before final approval by scientific committee of each society. RESULTS: No scientific evidence emerged from the literature. Thus, these guidelines are mainly based on the opinion of the expert panel. Guidelines for each issue are reported with the main points of arguments. The main question deals with the recommendation about doses for each drug: for lidocaine - up to 2mg/kg - "check contraindications, emergency truck available, no need of previous anesthetic consultation nor presence of anesthetic physician"; for ropivacaine - up to 1.5mg/kg, with a maximum of 100mg - the same but after intravenous line. Beyond these doses, SFAR guidelines have to be applied with the need of anesthetic physician. CONCLUSION: These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.


Assuntos
Espasticidade Muscular/tratamento farmacológico , Bloqueio Nervoso/métodos , Medicina Física e Reabilitação/métodos , Anestesiologia/educação , Anestésicos Locais/efeitos adversos , Anestésicos Locais/farmacocinética , Anestésicos Locais/uso terapêutico , Contraindicações de Medicamentos , Contraindicações de Procedimentos , França , Humanos , Neurônios Motores , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/normas , Dor Processual/etiologia , Dor Processual/prevenção & controle , Medicina Física e Reabilitação/educação , Ultrassonografia de Intervenção
18.
Curr Pain Headache Rep ; 23(6): 43, 2019 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-31123919

RESUMO

PURPOSE OF REVIEW: Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia. RECENT FINDINGS: Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.


Assuntos
Anestesia por Condução/normas , Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/normas , Doenças do Sistema Nervoso Periférico/prevenção & controle , Guias de Prática Clínica como Assunto/normas , Anestesia por Condução/efeitos adversos , Anestésicos Locais/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , Dor/tratamento farmacológico , Doenças do Sistema Nervoso Periférico/induzido quimicamente , Doenças do Sistema Nervoso Periférico/etiologia
19.
J Vet Dent ; 36(1): 40-45, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31138048

RESUMO

Regional anesthesia of the equine head is commonly performed to allow oral extraction of diseased teeth in the standing horse. The use of 4 blocks (infraorbital nerve, maxillary nerve, mental nerve, and mandibular nerve) is well documented for desensitization of dental quadrants for oral surgery for exodontia, but descriptions of associated complications are limited. A total of 270 regional nerve blocks were performed on 162 equine patients in a second opinion referral hospital setting. Criteria for inclusion in the study included a 24-hour stay in hospital, that the blocks be performed by one clinician and at minimum, a 2-week follow-up examination be performed. A total of 8 complications were identified in 7 patients representing a 2.96% incidence of complication. Complications included supraorbital hematoma (3), local hematoma (2), lingual self-trauma (2), and nerve block failure to desensitize (1). Treatment and management of complications are discussed. Complications associated with regional anesthesia may be reduced by reducing anesthetic volumes, precise needle placement, familiarity with the facial anatomy relevant to nerve blocks, adequate restraint, aseptic technique, postprocedural muzzling, and the use of a newly opened bottle of local anesthetic.


Assuntos
Bloqueio Nervoso/veterinária , Procedimentos Cirúrgicos Bucais/veterinária , Complicações Pós-Operatórias/veterinária , Animais , Feminino , Cavalos , Incidência , Masculino , Bloqueio Nervoso/efeitos adversos , Procedimentos Cirúrgicos Bucais/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos
20.
Anesthesiol Clin ; 37(2): 265-287, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31047129

RESUMO

Proper pain control is critical for ambulatory surgery. Regional anesthesia can decrease postoperative pain, improve patient satisfaction, and expedite patient discharge. This article discusses the techniques, clinical pearls, and potential pitfalls associated with those blocks, which are most useful in an ambulatory perioperative setting. Interscalene, supraclavicular, infraclavicular, axillary, paravertebral, erector spinae, pectoralis, serratus anterior, transversus abdominis plane, femoral, adductor canal, popliteal, interspace between the popliteal artery and capsule of the knee, and ankle blocks are described.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia por Condução/métodos , Anestesiologistas , Anestesia por Condução/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/métodos , Gestão de Riscos
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