Color Doppler ultrasonography of an agitated solution is predictive of accurate catheter placement for a continuous popliteal sciatic nerve block

Background Continuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success. Methods Eighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 min after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%). Results The degree of nerve blockade at 30 min as judged by median (10th, 90th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02). Conclusions Injection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound. Trial registration NCT01591603

Color Doppler Ultrasonography of an Agitated Solution is Predictive of Accurate Catheter Placement for a Continuous Popliteal Sciatic Nerve Block

Background: Continuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success.Methods: Eighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 minutes after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%).Results: The degree of nerve blockade at 30 minutes as judged by median (10 th, 90 th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02).Conclusions: Injection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound.Trial Registration: NCT01591603

INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT

Background: Opioid consumption and patient satisfaction are influenced by a surgeon’s pain management protocol and the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction include femoral nerve blockade and intra-articular injection; however, debate remains as to the most efficacious methodology. Hypothesis/Purpose: We hypothesize that intra-articular injection with ropivacaine and morphine is as efficacious as a femoral nerve block injection of ropivacaine, dexamethasone, and dexmedetomidine for post-operative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction. Methods: Charts were retrospectively reviewed for a single pediatric orthopedic surgeon performing BTB ACL reconstructions from 2013-2019. One hundred sixteen patients were identified, of whom 58 received intra-articular injection and 58 received single shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MME) consumed were tabulated for each patient. Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection vs 28.5MMEs in those with peripheral block (p=0.108). Consumption of MMEs was greater in the intra-articular group in the 0-4 hours period (7.1 MMEs vs. 4.6 MMEs, p=0.008). There was significantly less MME consumption in patients receiving intra-articular injection compared with peripheral block at 16-20 and 20-24 hours (3.2 MMEs vs. 5.6 MMEs, p=0.01; 3.8 MMEs vs. 6.5 MMEs, p<0.001 respectively). Mean pain scores were not significantly different over the 24-hour period (peripheral block=2.7, intra-articular injection=3.0, p=0.19). Conclusion: Moving away from the use of peripheral nerve block as an analgesic modality may be challenging given the multidisciplinary role of pain management in these patients. However, as Ramlogan et al. succinctly noted in their recent editorial “Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?” in the British Journal of Anesthesia, both orthopedic and anesthesia colleagues alike are beginning to recognize that it is a change that may benefit our patients. Our study strengthens this argument and shows that there is no significant difference in MME consumption between the femoral nerve block and intra-articular injection groups in the first 24 hours post-operatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require less opioids 16-24 hours post-operatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction. [Table: see text][Figure: see text]

Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone–Patellar Tendon–Bone Graft in an Adolescent Population

Background: Opioid consumption and patient satisfaction are influenced by a surgeon’s pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology. Hypothesis: We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone–patellar tendon–bone (BTB) ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient. Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block ( P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19). Conclusion: Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

ANESTHESIA FOR RENAL TRANSPLANT SURGERY IN ADULTS

Renal transplant surgery may be associated with important perioperative complications. In this scenario, the anesthetic technique should provide optimal conditions for the surgical team, guarantee hemodynamic stability and kidney perfusion, and adequate analgesia. Preoperative evaluation should always be performed. In the intraoperative period, standard monitoring is sufficient in most cases. General balanced anesthesia, alone or in combination with spinal anesthesia or peripheral block, is the technique of choice. Management of blood pressure during the surgery is crucial. Before reperfusion, a mean arterial blood pressure of 65 mmHg is recommended, increasing to 80–90 mmHg when reperfusion is imminent until the end of surgery. Vasopressors, such as ephedrine, may be necessary to achieve blood pressure targets. Mannitol and furosemide are commonly used to increase urine output. In the postoperative period, analgesia should be ensured.

Protocol of DEXPED trial: efficacy of intravenous dexamethasone, administered at the time of analgesic blocking of the lower limb, on postoperative pain in children: a randomised, placebo-controlled, double-blind trial

IntroductionDexamethasone is a drug used to prolong the postoperative analgesia in children after peripheral nerve blockade, although the dose usually used (0.2 mg/kg) has not been studied yet. This study is a monocentric, prospective, randomised, placebo-controlled, double-blinded study in a university hospital in France. The primary objective of the study is to evaluate the efficacy of 0.2 mg/kg intravenous dexamethasone on early postoperative pain in children aged 6–15 years, who require a lower limb peripheral nerve block following general anaesthesia.Methods and analysisEighty children, aged 6–15 years, undergoing surgery for which peripheral nerve lower limb blockade with ropivacaine following general anaesthesia are included. The inclusion criteria are: children aged 6–15 years, with American Society of Anaesthesiologists physical status I or II and scheduled for surgery requiring a peripheral block of the lower limb for analgesic purposes, with a preoperative anaesthetic evaluation between 90 and 2 days before the surgery, with informed consent from legal representatives. General anaesthesia is performed. The patient receives, according to his group, either 0.2 mg/kg of dexamethasone intravenously at the start of anaesthetic induction or the same volume of placebo. Then, the peripheral block of the lower limb is performed with ropivacaine. The primary outcome is the total doses of opioid administered (in mg/kg of morphine equivalent) within 24 hours postoperatively. The secondary objectives are the evaluation of the effect of a single-dose intravenous dexamethasone at the time of anaesthetic induction, on the following parameters: onset of postoperative pain, duration of motor block, postoperative nausea and vomiting within 24 hours.Ethics and disseminationThis study is conducted according to the principles of the Declaration of Helsinki and has been approved by the French national ethics committee and the National Drug Safety Agency. Findings of this study will be widely disseminated through conference presentations, reports, factsheets and academic publications.Trial registration numberNCT03618173.

Bilateral ultrasound-guided abdominal peripheral block in tap plane, tap - block

INTRODUCTION: Bilateral ultrasound-guided peripheral block (TAP - block) in the plane between the inner oblique abdominal muscle and the transversal abdominal muscle – TAP plane, is a regional anesthesia technique by infiltration of a local anesthetic, provides analgesia for operations involving the anterior abdominal wall. The analgesic effectiveness of the block decreases the consumption of opioid analgesics and non-steroidal anti-inflammatory drugs. AIM: In this study, we evaluated the intraoperative analgesic efficacy of bilateral TAP - block and the consumption of opioid analgesics in patients undergoing bilateral laparoscopic inguinal hernia repair. METHODS: The study was conducted with 35 patients, who were randomized into two groups. In the control group (group I), there are patients who received general anesthesia (GA), and experimental group (group II), were patients who have received general anesthesia and a bilateral tap block (GA + TAP). RESULTS: Patients with TAP-block (group II) have significantly lower fentanyl consumption compared to group I. CONCLUSION: Multimodal approach for the simultaneous administration of general anesthesia with a TAP block provides effective intraoperative analgesia and significantly reduces the perioperative consumption of opioid analgesics.

Double axillary vein variation diagnosed with ultrasound guidance during infraclavicular nerve block intervention

The use of ultrasound guidance increases the safety of peripheral block interventions by allowing anaesthesiologists to simultaneously see the position of block needle, the targeted nerves and surrounding vessels. In this report, we represented three patients diagnosed with double axillary vein variation with ultrasound guidance during infraclavicular nerve block intervention. The patients were scheduled for different types of upper limb surgeries. All patients received infraclavicular nerve block for anaesthetic management. A double axillary vein variation was diagnosed with ultrasound during block interventions. Hydro-location technique was used in all cases and the procedures were completed uneventfully. In the current literature, there is limited number of reports concerning double axillary vein variation. Detailed knowledge of the axillary anatomy is important to avoid complications such as intravascular injection during peripheral nerve block interventions. The use of ultrasound guidance and hydro-location technique should be considered for nerve blocks, especially in the axillary area.