Prolonged Use of a Continuous Peripheral Nerve Block Catheter for Analgesia after Pediatric Foot and Ankle Surgery

Continuous peripheral nerve blocks (CPNB) have a variety of indications and have been shown to be a safe and effective means of minimizing pain postoperatively. Early studies have indicated duration of catheter use greater than 48 hours as a main contributor to infection risk in CPNBs. Recent studies, though, have suggested that the risk of infection does not increase until 4 days after insertion. In the following case report, we recount our experience in using a continuous popliteal-sciatic peripheral nerve block for postoperative pain control in a pediatric patient following calcaneal and first metatarsal osteotomy. The catheter remained in place for 65 hours postoperatively without signs of local inflammation or infection. The prolonged CPNB use resulted in a significant decrease in postoperative opioid use and pain and increase in patient satisfaction when compared to the same procedure done one year prior on the opposite foot.

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Time Sequence of Sensory Changes after Upper Extremity Block

Anesthesiology ◽

10.1097/00000542-200407000-00025 ◽

2004 ◽

Vol 101 (1) ◽

pp. 162-168 ◽

Cited By ~ 23

Author(s):

Xavier Paqueron ◽

Marc E. Gentili ◽

Jean Claude Willer ◽

Pierre Coriat ◽

Bruno Riou

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Clinical Test ◽

Sensory Impairment ◽

Sensory Testing ◽

Early Assessment ◽

Sensory Assessment ◽

Nerve Blocks ◽

Sensory Fibers

Background Sensory assessment to estimate spread and effectiveness of a peripheral nerve block is difficult because no clinical test is specific for small sensory fibers. Occurrence of a swelling illusion (SI) during a peripheral nerve block corresponds to the impairment of small sensory fibers. The authors investigated the usefulness of SI in predicting successful peripheral nerve block by assessing the temporospatial correlation between progression of sensory impairment in cutaneous distributions anesthetized and localization of SI during peripheral nerve block installation. Methods Interscalene, infracoracoid, or sciatic nerve blocks were performed using a nerve stimulator and 1.5% mepivacaine in 53 patients, with a total of 201 nerves to be anesthetized. Pinprick, cold, warm, touch, and proprioception were assessed every 3 min, while patients were asked to describe their perception of size and shape of their anesthetized limb and localization of these illusions. Data are presented as mean +/- SD and percentage (95% confidence interval). Results Failure occurred in 12 cutaneous distributions out of a total of 201 theoretically blocked nerves. SI appeared earlier than warmth impairment (4.3 +/- 2.7 vs. 6.2 +/- 2.0 min; P < 0.05), always corresponding to successfully anesthetized cutaneous distributions, with the exception of 1 patient, who developed SI in 2 cutaneous distributions while sensory testing indicated failure in 1 distribution. SI successfully predicted the blockade of a cutaneous distribution with a sensitivity of 1.00 (0.98-1.00), a specificity of 0.92 (0.65-0.99), and an accuracy of 0.99 (0.97-1.00). Conclusions Swelling illusion may provide an early assessment of the success of a peripheral nerve block in unsedated patients.

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The Use of Long Acting Opioids to Prevent Rebound Pain Following Peripheral Nerve Blocks for Outpatient Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00248 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0024

Author(s):

Leah Herzog ◽

Sylvia H. Wilson ◽

Christopher E. Gross

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Pain Medication ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Pain Scores ◽

Ankle Surgery ◽

Patient Reported ◽

Long Acting

Category: Ankle; Bunion Introduction/Purpose: Peripheral nerve blocks have become an integral part of orthopedic surgery to assist with postoperative pain. However, 40% of patients who undergo a peripheral nerve block will experience rebound pain, which in turn, long-acting narcotics may be able to block. Unfortunately, this rebound pain can cancel out the potential benefits of decreased opioid medication use. Therefore, this study seeks to compare the difference in patient reported pain scores in those patients whom received long-acting opioid pain medication and those who did not. Methods: This is a retrospective review of patient-reported pain scores for 96 patients who underwent a peripheral nerve block for outpatient foot and ankle surgery. 48 patients either received three days of long-acting opioids or did not. Each patient was asked to fill out and return a pain diary as well as fill out a pain catastrophizing survey (PCS) at their postoperative appointment. The pain diary discussed their Visual Analogue Scale pain scores, amount of pain medication, and time they took the medicine. This data was then collected and compared via paired student t-tests for evaluation of significance. Results: Pain diaries were completed by 69 patients (72%). There were no significant differences between those comorbidities, types of procedures, age, or BMI between the groups. Mean postoperative pain scores did not differ between patients that did and did not receive postoperative extended release opioid medications (p = 0.226). Mean opioid consumption did not differ between groups (p = 0.945). There were no correlations between daily reported pain scores or the postoperative day with the highest pain score for those who received long acting opioid pain medication versus those who did not (r=0.336, p=0.550). Conclusion: Rebound pain is a difficult potential side effect of peripheral nerve blocks that currently does not have a preventative measure. This study was an attempted effort to help eliminate rebound pain, but there did not appear to be a significant benefit to adding long-acting opioid pain medication in addition to the peripheral nerve block and short-acting pain medication

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Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16183257 ◽

2019 ◽

Vol 16 (18) ◽

pp. 3257 ◽

Cited By ~ 3

Author(s):

Olufunke Dada ◽

Alicia Gonzalez Zacarias ◽

Corinna Ongaigui ◽

Marco Echeverria-Villalobos ◽

Michael Kushelev ◽

...

Keyword(s):

Peripheral Nerve ◽

Regional Anesthesia ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Opioid Consumption ◽

Orthopedic Procedures ◽

Negative Consequences ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

The Impact

Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.

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Lack of July effect in the utilization of neuraxial and peripheral nerve block in US teaching hospitals: a retrospective analysis

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101318 ◽

2020 ◽

Vol 45 (5) ◽

pp. 357-361

Author(s):

Sang Jo Kim ◽

Lauren Wilson ◽

Jiabin Liu ◽

David H Kim ◽

Megan Fiasconaro ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Neuraxial Anesthesia ◽

House Staff ◽

Teaching Hospitals ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Opioid Prescribing ◽

July Effect

BackgroundGiven the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether “July effect” affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.MethodsNeuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006–2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ2 test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.ResultsA total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).ConclusionUtilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

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Continuous Peripheral Nerve Blocks at Home for Treatment of Recurrent Complex Regional Pain Syndrome I in Children

Anesthesiology ◽

10.1097/00000542-200502000-00022 ◽

2005 ◽

Vol 102 (2) ◽

pp. 387-391 ◽

Cited By ~ 107

Author(s):

Christophe Dadure ◽

Frederic Motais ◽

Christine Ricard ◽

Olivier Raux ◽

Rachel Troncin ◽

...

Keyword(s):

Peripheral Nerve ◽

Complex Regional Pain Syndrome ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Pain Syndrome ◽

Nerve Blocks ◽

Rescue Analgesia ◽

Peripheral Nerve Blocks ◽

Children And Parents ◽

Bier Block

Background Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. Methods After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. Results Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. Conclusion Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.

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Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report -

Anesthesia and Pain Medicine ◽

10.17085/apm.21029 ◽

2021 ◽

Author(s):

Eric Ly ◽

Sai Velamuri ◽

William Hickerson ◽

David M. Hill ◽

Jay Desai ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Quadriceps Strength ◽

Complex Case ◽

Opioid Use ◽

Nerve Blocks ◽

Degloving Injury ◽

Continuous Peripheral Nerve Block ◽

Chronic Opioid Use

Background A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the ‘LIM’ block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here. CaseWe present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries.Conclusions The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.

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The selection of best anesthesiological technique for hip fracture surgery in older high-risk patients

Acta chirurgica iugoslavica ◽

10.2298/aci1203113r ◽

2012 ◽

Vol 59 (3) ◽

pp. 113-115 ◽

Cited By ~ 1

Author(s):

Nevenka Radic ◽

Kristina Radinovic ◽

Mihailo Ille ◽

Aleksandar Lesic ◽

Mirjana Ljubicic-Stojanovic ◽

...

Keyword(s):

Hip Fracture ◽

High Risk ◽

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Pathological Condition ◽

Older Age ◽

Spontaneous Respiration ◽

Nerve Blocks ◽

Selection Of

Introduction: Hip fracture is a pathological condition, more common in older age, i.e. in people over 65 years. The prevalence of this disorder is continuously increasing, simultaneously with higher age limit. In evaluation of risk for operation and anesthesia, older age itself represents higher risk and calls for special attention. In selection of anesthesiological technique, it is more usual to apply neuroaxial block or peripheral nerve block, which is more advantageous over general anesthesia. CASE REPORT: A female, 80-year old, patient B.D. was admitted to hospital for hip fracture, with the diagnosis of the right, lateral, basicervical femoral fracture. On admission, heart decompensation (decompensated dilated myocardiopathy), pulmonary edema and the left lateral pleural effusion were established. Due to high risk (ASA III) of intraoperative and postoperative complications, it was decided to apply combined peripheral nerve block. Using the neurostimulators, 3-in-1 block, lumbosacral block and sciatic nerve block were applied. During the operation, the patient was sedated by Propofol and had spontaneous respiration through the laryngeal mask. Intra- and postoperatively, the patient?s hemodynamics was stable. Conclusion: Peripheral nerve blocks are safe and effective anesthesiological technique, which may reduce the mortality in patients with the hip fracture and maintain the hemodynamic stability, both during and after the surgical intervention.

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Efficacy of perineural versus intravenous dexmedetomidine as a peripheral nerve block adjunct: a systematic review

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-102353 ◽

2021 ◽

pp. rapm-2020-102353

Author(s):

Nasir Hussain ◽

Chad M Brummett ◽

Richard Brull ◽

Yousef Alghothani ◽

Kenneth Moran ◽

...

Keyword(s):

Systematic Review ◽

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Intravenous Route ◽

Motor Blockade ◽

Nerve Blocks ◽

Sensory Blockade ◽

Moderate Quality ◽

Quality Evidence

BackgroundDexmedetomidine is an effective local anesthetic adjunct for peripheral nerve blocks. The intravenous route for administering dexmedetomidine has been suggested to be equally effective to the perineural route; but comparative evidence is conflicting.ObjectivesThis evidence-based review evaluated trials comparing the effects of intravenous to perineural dexmedetomidine on peripheral nerve block characteristics in adult surgical patients. Our primary aim was to evaluate the durations of sensory and motor blockade. Duration of analgesia, onset times of sensory and motor blockade, analgesic consumption, rest pain, and dexmedetomidine-related adverse events were evaluated as secondary outcomes.Evidence reviewWe sought randomized trials comparing the effects of intravenous to perineural dexmedetomidine on peripheral nerve block characteristics. The Cochrane Risk of Bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation criteria was used to evaluate the quality of evidence for when an outcome was reported by at least three studies.ResultsTen studies compared intravenous and perineural dexmedetomidine in the setting of upper extremity blocks (seven), lower extremity blocks (two), and truncal block (one). The doses of dexmedetomidine supplementing long-acting local anesthetics varied between a predetermined dose (50 μg) and a weight-based dose (0.5 μg/kg–1.0 μg/kg). Clinical diversity precluded quantitative pooling; and evidence is presented as a systematic review. Compared with the intravenous route, moderate quality evidence found that perineural dexmedetomidine prolonged the duration of sensory blockade in four of six trials and motor blockade in five of seven trials. Perineural dexmedetomidine also hastened the onset of sensory and motor blockade in three of six trials. No differences were reported for the remaining outcomes; and intravenous dexmedetomidine was not superior for any outcome in any of the trials.ConclusionsModerate quality evidence appears to suggest that intravenous dexmedetomidine is an inferior peripheral nerve block adjunct compared with perineural dexmedetomidine. Perineural dexmedetomidine is associated with longer durations and faster onset of sensory and motor blockade.

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