Cryoablation for Chest Wall Trauma: A Brief Report

Respiratory failure secondary to rib fractures is a major source of morbidity and mortality in trauma patients, particularly in older populations. Management of pain in these patients is complex due to the nature of the injuries. We present 3 patients who underwent a video-assisted thoracoscopic cryoablation of intercostal nerves for pain control after chest trauma. None of the patients developed post-operative complications related to poor respiratory status such as pneumonia or atelectasis. At one-month clinic follow-up, all patients reported no chest pain and were not using opiate analgesics. In patients for whom there is a contraindication to rib fixation in the setting of unstable rib fractures, cryoablation may be a method by which to improve respiratory status and decrease ventilator dependency due to pain. Cryoablation of intercostal nerves may provide a more durable and clinically feasible solution to aid in the healing process of these patients.

The external oblique intercostal block: anatomical evaluation and case series

Study Objective We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block. Design A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block. Setting Cadaver lab and operating room. Patients Two unembalmed cadavers and 22 patients. Interventions Bilateral ultrasound-guided EOI blocks on cadavers with 29 ml of bupivacaine 0.25% with 1 ml of India ink; single-injection or continuous EOI blocks in patients. Measurements Dye spread in cadavers and loss of cutaneous sensation in patients. Main Results In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7–T10. We also found consistent dermatomal sensory blockade of T6–T10 at the anterior axillary line and T6–T9 at the midline in patients receiving the EOI block. Conclusions We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7–T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6–T10 at the anterior axillary line and T6–T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia.

APPLICATION OF THE MODIFIED PECS BLOCKADE DURING RECONSTRUCTIVE AND AESTHETIC SURGERY ON THE MAMMARY GLANDS

Existing methods of anesthesia, drugs used in the field of breast plastic surgery have a number of features compared to anesthesia in the practice of general surgery. In particular, techniques of regional blockades, such as interfascial blocks PECS 1 and PECS 2 are taken into account. Their effectiveness in comparison with standard methods of anesthesia for different types of interventions on the breast is subject to further discussion. Thus, the article presents the results of efficiency in the implementation of the author's development - a modified PECS-block during reconstructive and aesthetic surgery on the mammary glands. Material and methods. During 2018-2020, 58 women (average age 36,8 ± 10,8 years) were included in the prospective study, who underwent low-flow inhalation anesthesia with sevoflurane during surgery, and in the postoperative period were divided into two subgroups: 1) subgroup 1, in whom regional anesthesia according to the author's method used; 2) subgroup 2 with nalbuphine analgesia. At the first visit, clinical and laboratory, instrumental ultrasound examination, completed informed consent cards of patients, as well as long-term observation cards were filled in. The method of postoperative analgesia developed by the author's method is, in essence, a combination of PECS 1 and PECS 2 blockades. The anesthetic solution was administered so as to effectively block the intercostal nerves that run along the posterior surface of the chest and extend outward into the parasternal region. For statistical analysis of the obtained results we used a package of general statistic data “Statistica for Windows” version 6.0 (Stat Soft inc., USA). At p<0, 05, the difference was considered statistically significant. Results. It was found that the use of modified PECS-block was characterized by a shortening of the verticalization time by 58,8%, compared with the introduction of nalbuphine and 2,16 times in the absence of postoperative anesthesia. The absolute efficiency (AE,%) of the modified PECS-block relative to the verticalization time was 68,0% higher compared to the use of nalbuphine, with a probable relative efficiency (RR, p<0,05) and the odds ratio (OR, p<0,05). 3 hours after the intervention of AE modified PECS-block relative to the intensity of pain less than 1 point was 89,0%, with a clinical efficiency of 60,0% relative to the use of nalbuphine, probable RR (p<0,05) and OR (p<0,05). The majority of patients who underwent modified PECS-block rated their physical and motor activity by more than 2 points (86,0%), while using nalbuphine the part was only 43.0% (p<0,05). The reversal, moderate regression relationship between pain self-esteem and physical activity (r=-0.46, p<0.05) persisted for 3 hours after the intervention. Against the background of the modified PECS block, there was no cases of postoperative nausea, in contrast to nalbuphine (AE – 18,0%, RR – 0,02 [0,003-0,97], p<0,05; HS – 0,02 [0,004-0,87], p<0,05). Regarding the parameters of cardio hemodynamics, it was found that against the background of nalbuphine there was an increase in heart rate to 29,3% after 1 hour, by 48,6 and 39,7% after 3 and 8 hours, compared with the modified PECS-block. The tendency to high (greater than 140 mm Hg) and high normal (greater than 130 mm Hg) blood pressure on the background of nalbuphine, in contrast to the modified PECS-block, where the CAT values during the 1st day stayed in the range of optimal pressure (110-130 mm Hg).

Description of an Ultrasound-Guided Transverse Approach to the Transversus Thoracis Plane Block and Evaluation of Injectate Spread in Canine Cadavers

Transversus thoracis plane (TTP) block has demonstrated to produce analgesia in humans undergoing median sternotomy. The objectives of the study were to describe an ultrasound-guided transverse approach to the transversus thoracis plane (t-TTP) and to evaluate the spread of two injectable volumes in canine cadavers. Two cadavers were used to describe relevant gross anatomy of the ventral thoracic area and sonoanatomy between the fifth and sixth costal cartilages. Then, eight cadavers were used to describe the ultrasound-guided injection into the TTP and were dissected to evaluate the injectate spread and the intercostal nerves staining with two different dye-lidocaine volumes: low volume (LV) 0.5 mL kg−1 and high volume (HV) 1 mL kg−1. To compare the spread between both volumes the Fisher’s exact test and Wilcoxon signed-rank test were used. The solution spread along the TTP after all injections, staining a median number (range) of 3 (2–4) and 4 (3–5) nerves with LV and HV, respectively (p = 0.014). The injection of HV versus LV increases the number of stained nerves. Ultrasound-guided t-TTP is a feasible technique that provides staining of several intercostal nerves with a single injection site, so it could be useful to provide analgesia to the ventral chest wall.

Nerve Transfers for Restoring Elbow Flexion in Brachial Plexus Palsy

Nerve transfers (NT) consist in sectioning a donor nerve and connecting it to the distal stump of a recipient unrepairable nerve. For elbow flexion restoration in brachial plexus palsy (BPP) we used different NT: 1) GF motor Ulnar Nerve to Biceps nerve (Oberlin technique), 2) Double fascicular median/ulnar to biceps/brachialis nerve transfer (Mackinnon), 3) InterCostal Nerves (ICN) to MCN (+/− nerve graft), 4) Medial Pectoral Nerve (MPN) to MCN, 5) ThoracoDorsal Nerve (TDN) to MCN, 6) Spinal Accessory Nerve (SAN) to MCN transfer, 7) Phrenic Nerve (PhN) to MCN, 8) Cervical Plexus C3-C4 to MCN and 9) Contralateral C7 (CC7). I want to present my personal experience using the phrenic nerve (PhN), the intercostal nerves (ICN) and Oberlin’s technique. The aim of this retrospective study is to evaluate the results of this procedure in BPP. NT is an important goal in BPP. ICN transfer into the nerve of biceps for elbow flexion recovery is a reliable procedure in BPP. ICN transfer for triceps offers a positive alternative (Carroll transposition). Oberlin technique is simple and offers better results in a shorter amount of time and is an effective and safe option.

Transversus Abdominis Plane and Rectus Sheath Blocks

Chapter 9 discusses truncal peripheral nerve blocks, which are utilized for supplemental analgesia for abdominal surgeries by providing local anesthesia to the anterior abdominal wall. These blocks are adjuvants because they will not block visceral pain. Unilateral analgesia to the skin, muscles, and parietal peritoneum of the abdominal wall is achieved. The transversus abdominis plane block (TAP) reliably provides analgesia to the lower abdominal wall in the T10–L1 distribution. Rectus sheath blocks anesthetize the terminal branches of the lower thoracic intercostal nerves and provide midline analgesia from the xiphoid process to the umbilicus. Surgical indications for TAP blocks include laparotomies, laparoscopies, inguinal hernia repairs, and appendectomies. Rectus sheath block indications include midline surgeries such as single-port appendectomies and umbilical hernia repairs.

Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion

The gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7–12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication.

Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in “Enhanced Recovery after Cardiac Surgery (ERACS)” protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

Use of Spinal Anaesthesia with Anaesthetic Block of Intercostal Nerves Compared to a Continuous Infusion of Sufentanyl to Improve Analgesia in Cats Undergoing Unilateral Mastectomy

Unilateral mastectomy is a common surgical procedure in feline species and requires postoperative pain management. Our study aimed to evaluate the analgesic efficacy of subarachnoid anaesthesia combined with an intercostal nerve block, in comparison with the use of sufentanyl citrate administered as a constant-rate infusion (CRI). Twenty cats were randomly divided into two groups (n = 10/group) based on the analgesic protocol used: the first received loco-regional anaesthesia with levobupivacaine (LR group), and the second received a CRI of sufentanyl (SUF group). The evaluation criteria during surgery were the need for a bolus of fentanyl in the event of an increased heart rate or increased blood pressure. In the postoperative period, the levels of comfort/discomfort and pain were used to obtain a score according to the UNESP-Botucatu multimodal scale. Subjects who scored above seven received analgesic drug supplementation. Intraoperative analgesia was satisfactory, with good haemodynamic stability in both groups. Four patients in the LR group required an extra dose of methadone after they achieved the sternal decubitus position, whereas those in the SUF group required many more doses. The analgesia achieved in the LR group was more satisfactory than that in the SUF group.