Depth of cervical plexus block and phrenic nerve blockade: a randomized trial

Background and objectivesCervical plexus blocks are commonly used to facilitate carotid endarterectomy (CEA) in the awake patient. These blocks can be divided into superficial, intermediate, and deep blocks by their relation to the fasciae of the neck. We hypothesized that the depth of block would have a significant impact on phrenic nerve blockade and consequently hemi-diaphragmatic motion.MethodsWe enrolled 45 patients in an observer blinded randomized controlled trial, scheduled for elective, awake CEA. Patients received either deep, intermediate, or superficial cervical plexus blocks, using 20 mL of 0.5% ropivacaine mixed with an MRI contrast agent. Before and after placement of the block, transabdominal ultrasound measurements of diaphragmatic movement were performed. Patients underwent MRI of the neck to evaluate spread of the injectate, as well as lung function measurements. The primary outcome was ipsilateral difference of hemi-diaphragmatic motion during forced inspiration between study groups.ResultsPostoperatively, forced inspiration movement of the ipsilateral diaphragm (4.34±1.06, 3.86±1.24, 2.04±1.20 (mean in cm±SD for superficial, intermediate and deep, respectively)) was statistically different between block groups (p<0.001). Differences were also seen during normal inspiration. Lung function, oxygen saturation, complication rates, and patient satisfaction did not differ. MRI studies indicated pronounced permeation across the superficial fascia, but nevertheless easily distinguishable spread of injectate within the targeted compartments.ConclusionsWe studied the characteristics and side effects of cervical plexus blocks by depth of injection. Diaphragmatic dysfunction was most pronounced in the deep cervical plexus block group.Trial registration numberEudraCT 2017-001300-30.

Is lumbar erector spinae plane block (L-ESPB) a lumbar plexus block?: a case report of three cases

Background Lumbar erector spinae plane block (L-ESPB) is being used in fractured hip patients for the postoperative pain relief and as a sole anesthetic technique. Various clinical and cadaveric studies have differences of opinion about its mechanism of action and pathways of local anesthetic spread; however, the role of lumbar plexus (LP) in the mechanism of action is still not considered. In our clinical experience, we observed that the action on LP could be a pathway for the analgesic action of local anesthetic along with paravertebral spread. Case presentation We report here three cases of the fractured hip who were given L-ESPB for postoperative pain management. The radiological examination was done after injection of non-ionic contrast to know the spread of local anesthetic. In two cases, the contrast spread was seen towards LP and in one case spread of contrast was observed towards the paravertebral area. Conclusions Effect of local anesthetic on the lumbar plexus is one of the plausible pathways in L-ESPB for its analgesic mechanism of action.

Ultrasound-Guided Lumbar Plexus Block Reduces Emergence Agitation in Children Undergoing Hip Surgery: A Prospective Randomized Controlled Trial

Background Emergence agitation (EA) is a common and challenging postoperative problem in children emerging from general anesthesia. It is associated with self-injury, increases stress on healthcare team members and postoperative maladaptive behavioral changes. However, no completely effective prevention has been found for EA. Pain is considered to be an important contributor to EA. Ultrasound-guided lumbar plexus block is a safe and effective anesthetic technique that can provide satisfactory pain relief in pediatric hip surgery. We aim to investigate the effect of ultrasound-guided lumbar plexus block on emergence agitation in children undergoing hip surgery. Methods This prospective, randomized, controlled study was conducted in children aged 1-6 yr undergoing elective hip surgery. Subjects were randomly assigned to receive either ultrasound-guided lumbar plexus block combined with general anesthesia (Group Block, n=60) or routine general anesthesia (Group Control, n=60). The primary outcome was the incidence of EA at 30 min after emergence from general anesthesia, assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The secondary outcomes included the incidence of severe EA, postoperative pain evaluated by the Children’s Hospital of eastern Ontario Pain Scale (CHEOPS) and the incidence of postoperative adverse complications. PAED, CHEOPS were measured at 0, 5, 10, 20, and 30 min after emergence from anesthesia. Results The incidence of EA was significantly lower in Group Block than in Group Control [13.3% vs. 43.3%, odds ratio (OR) 0.201, 95% confidence interval (CI) 0.082to 0.496, p<0.001]. Group Block had a lower incidence of severe EA than Group Control [3.3% vs. 18.3%, odds ratio (OR) 0.154, 95% confidence interval (CI) 0.032 to 0.727, p=0.019]. CHEOPS was lower in Group Block than in Group Control [mean (95%CI), 4.5(4.4-4.6) vs.4.9 (4.8-5.0), p<0.001]. Conclusion Ultrasound-guided lumbar plexus block could decrease the incidence and severity of emergence agitation in children undergoing hip surgery effectively. Trial registration: Chinese Clinical Trial Registry: ChiCTR-INR-17011525 (30/05/2017)

Early and Late Haemodynaemic Effects after Adding Fentanyl to Bupivacaine-Lignocaine Mixtures in Supraclavicular Brachial Plexus Block: A Randomized Control Trial

Background Objectives: Haemodynamic changes are very crucial issues during regional anaesthesia. The purpose of the present study was to observe the immediate and late haemodynaemic effects after adding fentanyl to bupivacainelignocaine mixtures in supraclavicular brachial plexus block. Methodology: This randomized clinical study was conducted in the Department of Anesthesiology in Chittagong Medical College Hospital (CMCH) from March 2011 to May 2012 for a period of one year. All patients with the age group of 18 to 65 years who were selected for upper limb surgery distal to the mid arm were the study population. The random allocation of the patient was done into Group A patients (control group) who were received injection Bupivacaine (0.25%) with injection lignocaine A (1%) with injection Normal saline (0.9%). Group B patients (treatment group) were received injection bupivacaine (0.25%) with injection Ligonocaine A (1%) with injection fentanyl. With all aseptic precaution, supraclavicular brachial plexus block was done using paresthesia technique. Pulse and blood pressure were measured at baseline, intra-operatively and post-operatively. Result: A total of 60 patients were enrolled in this study with 30 patients in each group named group A and group B. The mean age of group A and group B were 32.43±12.25 and 34.90±13.05 respectively (p=0.453). The mean pulse rate of group A (79.53±5.03) and group B (78.10±4.26) at baseline level increased at the time of injection (88.30±5.77 and 85.63±4.87 respectively). At 8 hours interval mean pulse rate of group A was 86.47±5.51 compared to that of group B (86.07±3.08). The mean systolic blood pressure of group A (126.50±18.21) and group B (120.07±11.61) at baseline level increased at 0 minute at the time of injection (129.70±15.34 and 123.17±10.57 respectively). The mean diastolic blood pressure of group A (71.73±11.20) and group B (72.73±11.45) at baseline level increased at 0 minute (75.97±12.74 and 75.80±12.85 respectively). At 8 hrs interval mean diastolic pressure of group A was71.73 ±11.20 compared to that of group B (71.73±11.20). Conclusion: In conclusion there is no significant immediate or late haemodynaemic effects after adding fentanyl to bupivacaine-lignocaine mixtures in supraclavicular brachial plexus block. J Bangladesh Coll Phys Surg 2022; 40: 17-22

Selective Fasciectomy in Dupuytren’s Contracture: An Experience of A Specialized Tertiary Hospital in Bangladesh

Background: Dupuytren’s disease is a benign yet disabling, irreversible, progressive fibroproliferative condition affecting the palm and fingers, leading to flection contracture of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.Objective: To evaluate results of selective fasciectomy to correct the deformity of MCP and PIP joints and observe the complications.Methods: This crosssectional study was done on 30 patients of Dupuytren’s contracture treated by selective fasciectomy, between January 2015 and December 2018, in Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Selective fasciectomy was done under brachial plexus block, tourniquet control and loupe magnification. Brunner zigzag incision was used. Indications for surgery was MCP flection contracture more than 30⁰ and any degree of PIP flection contracture. Postoperatively hand was immobilised in extension of MCP and PIP joints for 2 weeks and then active and passive movements were encouraged and intermittent splinting for 10 weeks (only at night in last 6 weeks).Results: Among 30 patients, 24 (80%) patients were male, 6 (20%) were female; mean age was 62 years (56-74 years). 12 (40%) cases were bilateral, ring and little fingers involvement were seen in most cases (92%). Mean MCP correction was 53⁰ and mean PIP correction was 34⁰ (p<0.001). There were 3 digital nerve injuries peroperatively which were repaired/reconstructed and protective sensation regained in repaired nerve area at 1 year and 3 (10%) marginal skin loss postoperatively which healed secondarily. Superficial wound infection developed in 3 (10%) patients which healed on dressing and antibiotics. Complex regional pain syndrome developed in 2 (6.66%) patients which were mild and resolved on conservative management. 3 (10%) patients developed scar sequilae which were mild and resolved on conservative treatment. Radial digital artery injury was observed in 1 (3.33%); however, no ischaemic insult was observed postoperatively. 2 (6.66%) patients developed recurrence of the disease who were more than 70 years old; however, they declined further intervention.Conclusion: Selective fasciectomy is an easy and effective procedure with less complication to correct the deformities and improve the gripstrength significantly in Dupuytren’s contracture patients.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 41-46