Erector Spinae Plane Block versus Continuous Perineural Local Anesthetic Infusion for Postoperative Pain Control After Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A Matched Case-Control Comparison.

OBJECTIVE: The purpose of this study was to determine if single injection erector spinae plane blocks are associated with improved pain control, opioid use, numbness, length of stay, or patient satisfaction compared to intraoperatively placed continuous perineural infusion of local anesthetic after decompression of neurogenic thoracic outlet syndrome. METHODS: This is a retrospective cohort study at a tertiary academic center of eighty patients that underwent supraclavicular decompression for thoracic outlet syndrome between May 2019 and January 2020. Forty consecutive patients treated with single-injection preoperative erector spinae plane blocks were retrospectively compared to 40 age- and gender-matched controls treated with continuous perineural infusion. RESULTS: The primary outcome of mean pain scores was not significantly different between the erector spinae and perineural infusion groups over the three-day study period (4.2-5.3 vs 3.0-5.1 P=0.08). On post-operative day 0, mean pain scores were significantly higher in the erector spinae group (4.2 vs 3.0, P=0.02). While statistically significant, the score was still lower in the erector spinae group on day 0 than on day 1,2, or 3 in either group. Opioid use, nausea, length of stay and patient satisfaction were also similar. Upper extremity numbness was significantly less severe in the erector spinae group (36% vs 73% moderate-extreme, P=0.03) at 6-month follow-up. CONCLUSIONS: Seventy-two-hour perineural local anesthetic infusion did not provide superior analgesia compared to preoperative single-injection erector spinae blocks. Furthermore, there was significantly less long-term postoperative numbness associated with erector spinae blocks compared to perineural local anesthetic infusion.

The current role of ultrasound use in teaching regional anesthesia: a survey of residency programs in the United States.

BACKGROUND AND OBJECTIVES: The purpose of this survey was to determine the current teaching practices of regional anesthesia and the prevalence of ultrasound use in guiding peripheral nerve blocks in the academic institutions across the United States. METHODS: A survey was distributed to all American Board of Anesthesiology-accredited residency programs via email and/or the U.S. postal service. The survey was designed to determine the number of peripheral nerve blocks (PNBs) performed, the role of the ultrasound guidance, the barriers to its use, and the methods by which teaching physicians acquired their ultrasound skills. RESULTS: We received 82 responses (62%) of the 132 programs surveyed. Eighty-eight percent of the responding programs performed more than 20 PNBs/week and 46% performed more than 40 PNBs/week. Three-fourths of the respondents relied on ultrasound to guide the majority of single injection and continuous PNBs. When using ultrasound, most programs (79%) used real-time ultrasound without nerve stimulator. Most teaching physicians supervising ultrasound-guided PNBs received their training via workshops and/or from other colleagues. The three main reasons for using ultrasound were to 1) achieve a higher success rate; 2) improve safety; and 3) teach anesthesia trainees. However, the three main barriers to using ultrasound were 1) lack of training; 2) perceived decreased efficiency; and 3) the lack of immediate availability of equipment. Overall, ultrasound was less utilized to guide lower extremity vs upper extremity PNBs. CONCLUSIONS: Ultrasound-guided PNBs are universally taught across residency programs in the United States. Most teaching physicians believe that ultrasound increases PNB's success and improves safety of regional anesthesia. Barriers to ultrasound use are lack of faculty training and unavailability of ultrasound equipment.

Contralateral local anesthetic spread from an outpatient interscalene catheter.

PURPOSE: Ambulatory continuous infusions have been associated with improved analgesia and few serious complications. This report describes an unusual case of a patient with a continuous interscalene nerve block who developed a contralateral upper extremity sensory block. The complication did not occur until postoperative day two while the patient was at home. CLINICAL FEATURES: A 56-yr-old woman had a continuous interscalene catheter placed for arthroscopic lysis of adhesions of her shoulder. The insertion needle was initially injected with 0.5% ropivacaine 25 mL (1:400,000 epinephrine), producing a unilateral interscalene block. Postoperatively, the patient was started on a continuous interscalene infusion of 0.2% ropivacaine at 8 mL·hr(-1) via a disposable infusion pump. The next day, the patient had a unilateral brachial plexus block and an associated Horner's syndrome and was discharged home with the infusion. On the morning of the second postoperative day, the patient developed ipsilateral and contralateral Horner's syndrome with associated numbness in both shoulders. The catheter was removed and symptoms resolved four hours later. CONCLUSIONS: Ambulatory continuous infusions are typically associated with few serious complications and a favourable safety profile. This case demonstrates that unexpected complications can still occur even after days of normal operation. Based on our previous experience, we believe this to be a rare but potentially serious event that requires awareness by those discharging patients with continuous infusions of local anesthetics.

A practical guide to commonly performed ultrasound-guided peripheral-nerve blocks.

PURPOSE OF REVIEW: Regional anesthesia has experienced a tremendous renaissance of interest over the past several years. Much of this renewed enthusiasm among clinicians is due to the increased usage of ultrasound guidance for peripheral-nerve blocks. This review serves as a useful foundation for the most commonly employed ultrasound-guided blocks utilized by the clinician. RECENT FINDINGS: With recent advances in both sonographic capability and access for anesthesia providers, many peripheral-nerve blocks have become quite amenable to being placed with ultrasound guidance. In addition, the subspecialty of ultrasound-guided regional anesthesia is being further pioneered via both anatomical and pharmacological studies. SUMMARY: With ultrasound guidance, the regional anesthesiologist has yet another tool to enhance both the accuracy and success of peripheral-nerve blockade. This article serves to display the most clinically relevant nerve blocks utilized in the perioperative setting. It is meant to be used as a clinical starting point for the development of regional anesthesia skills.