Patients' experiences with multiple stimulation axillary block for fast-track ambulatory hand surgery

Sedation efficacy of different dose of remimazolam with sufentanil for nerve block in young and elderly patients: a randomized, controlled study

Purpose

Anxiety and pain commonly occur during nerve block, we aimed to investigate the sedation efficacy of different doses of remimazolam with sufentanil in young and elderly patients.

Methods

In this randomized trial, patients aged 18–85 years who underwent nerve block was enrolled. All patients received sufentanil 0.08 μg/kg for analgesia. Young patients (age < 65 years) were randomized into the control group (Group C, 0.9% saline), medium-dose remimazolam (Group M, 0.06 mg/kg) and high-dose remimazolam group (Group H, 0.08 mg/kg). Elderly patients (age ≥ 65 years) were randomized into the Group C, low-dose remimazolam group (Group L, 0.04 mg/kg) and Group M. Primary outcome was the success rate of procedure sedation. Respiratory depression and hypoxia were the interested safety outcomes.

Results

Ninety young and 114 elderly patients were enrolled, respectively. In comparison with Groups C and M, young patients in Group H had the highest success rate of procedure sedation (80.0 vs. 73.3 vs. 43.3%, P = 0.006). Elderly patients in Groups M and L had similar success rates of procedure sedation, which were significantly higher than that in Group C (78.9 vs. 78.9 vs. 50.0%, P = 0.007). In elderly patients, the incidence of respiratory depression and hypoxia tended to be higher in Group M than those in Groups L and C (both P < 0.001).

Conclusion

Remimazolam 0.08 mg/kg provided the best sedation efficacy in young patients while remimazolam 0.04 mg/kg with the trend of less respiratory adverse events was more optimal for elderly patients.

Trial registration

http://www.chictr.org.cn/showproj.aspx?proj=122016.

Effect of nerve localization using a pen device on the success of axillary brachial plexus block

Objective

The effectiveness of axillary brachial plexus block (ABPB) performed using peripheral nerve stimulation (PNS) alone was compared with PNS preceded by nerve localization using a pen device, enabling nerve mapping without puncturing the skin.

Methods

Patients undergoing unilateral hand or forearm surgery suitable for ABPB were randomly assigned to receive either PNS alone (pen − group) or PNS preceded by nerve localization using a pen device (pen + group). Parameters related to the block procedure and patient comfort were assessed.

Results

Thirty patients were included in each group. The block performance time was longer in the pen + group than the pen − group despite a reduced number of needle insertions. The complete block rate was higher and intraoperative analgesic usage lower in the pen + group compared with the pen − group. Patient satisfaction and complication rates were similar in the two groups.

Conclusion

The pen device seems to be a helpful addition to PNS for ABPB, with improved results in terms of block success and patient comfort, but further studies are needed to confirm these findings.

Expected and experienced pain during epidural catheter insertion

BACKGROUND

Insertion of an epidural catheter for pain relief is frequently used in anaesthetic practice. Little is known regarding patients' expected vs. experienced pain and discomfort due to the epidural block procedure. The purpose of this study was to investigate the expected and experienced pain, respectively, associated with the epidural procedure in patients undergoing major abdominal surgery.

METHODS

Thirty adult, unselected patients scheduled for elective major abdominal surgery were included in this study, which was approved by the ethics committee. Pre-operative insertion of an epidural catheter had to be a part of the anaesthetic routine procedure. Immediately before the epidural procedure, the patients were asked to grade the pain they expected from the procedure on an 11-point numeric rating system scale, ranging from 0 to 10, where '0' is no pain and '10' is worst imaginable pain. When the procedure had been carried out, the patients were once again asked to grade how much pain they had experienced.

RESULTS

The median expected pain as a result of the epidural procedure was 5.0. Median experienced pain was 2.0. The median difference between the expected and experienced pain was -3.0 (P < 0.0001). The only patient who expected less pain than she subsequently experienced had a paraesthetic sensation. Gender, age, or previous experience from central neuraxial block did not significantly affect neither expected nor experienced pain.

CONCLUSIONS

Patients expect significantly more pain than they experience from receiving an epidural block.

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques

STUDY OBJECTIVE

To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop.

DESIGN

Randomized-prospective, observational study.

SETTING

University surgical center.

PATIENTS

100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm.

INTERVENTIONS

Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location.

MEASUREMENTS

Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia.

MAIN RESULTS

No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 +/- 1.2 vs 1.5 +/- 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 +/- 2.9 vs 2.2 +/- 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery.

CONCLUSIONS

In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.

[Anxiety: an independent factor of axillary brachial plexus block failure?]

OBJECTIVE

To evaluate the impact of the anxiety level using Spielberger test on axillary block success.

STUDY DESIGN

Prospective double-blind study.

PATIENTS AND METHODS

An axillary brachial plexus block was performed with a nerve stimulator for all patients undergoing elective or emergency upper limb surgery. Spielberger test result was blinded for both patient and anaesthesiologist performing the block. Time to perform the block (minutes) was measured. Anxiety and pain scores were assessed, using a numeric scale (NS), at different time. Successful block was defined as complete sensory blockade combined with painless during surgical incision. Data were compared using Spearman test and multivariate logistical regression analysis.

RESULTS

Patients (184) were included (elective surgery=62%; emergency=38%). Failure rate was 10%. On multivariate logistical regression analysis, time to perform the block and NS anxiety score before starting the block were associated with block failure. Spielberger score correlated with NS anxiety score before puncture (Rho = 0,586, p<10(-4)). Anxiety level was increased in emergency context.

CONCLUSION

Patient's anxiety level before axillary brachial plexus block is a risk factor of failure, especially in emergency condition. We suggest anesthesiologists to evaluate patient anxiety prior to block performance. A specific anxiolytic treatment may be recommend in some cases.

Multiple injection axillary brachial plexus block: influence of obesity on failure rate and incidence of acute complications

BACKGROUND

Obesity has been associated with an increased failure rate in regional anesthesia, but specific block techniques have not been evaluated. We hypothesized that obesity decreases the success rate of axillary brachial plexus block.

METHODS

We prospectively studied axillary brachial plexus blocks performed by experienced anesthesiologists in patients scheduled for upper limb surgery. A triple-injection technique was given to block the musculocutaneous and the median nerves with 6 mL and 10 mL ropivacaine 0.5%, respectively, and the radial nerve with 20 mL ropivacaine 0.5%. For the median and radial nerves, distal motor responses (wrist or fingers) were identified. Success was defined as adequate anesthesia allowing surgery to be performed without additional medications. Acute complications were noted. Before leaving the postanesthesia care unit, patient's satisfaction with anesthesia was collected.

RESULTS

Of 605 patients, 85 were obese (body mass index > or = 30 kg/m(2)). The success rate was 97% overall, 91% in the obese and 98% in the non-obese patients (P = 0.003). Additional nerve blocks at the elbow were performed more frequently in obese (7%) than in non-obese patients (2%; P = 0.007). Acute complications (mainly vascular puncture) were more frequent in obese than in non-obese patients (27% vs 9%; P < 0.001). Patient satisfaction was 87% in the obese and 94% in the non-obese patients (P = 0.03).

CONCLUSIONS

Obesity increased the failure rate and immediate complications of axillary brachial plexus block. Furthermore, more obese patients were dissatisfied with their anesthesia.

A prospective, randomized comparison between ultrasound-guided supraclavicular, infraclavicular, and axillary brachial plexus blocks

BACKGROUND

This prospective, randomized, observer-blinded study compared ultrasound-guided supraclavicular (SCB), infraclavicular (ICB), and axillary (AXB) brachial plexus blocks for upper extremity surgery of the elbow, forearm, wrist, and hand.

METHODS

One hundred twenty patients were randomly allocated to receive an ultrasound-guided SCB (n = 40), ICB (n = 40), or AXB (n = 40). Performance time (defined as the sum of imaging and needling times) and the number of needle passes were recorded during the performance of the block. Subsequently, a blinded observer recorded the onset time, block-related pain scores, success rate (surgical anesthesia), and the incidence of complications. The main outcome variable was the total anesthesia-related time, defined as the sum of performance and onset times.

RESULTS

No differences were observed between the 3 groups in terms of total anesthesia-related time (23.1-25.5 mins), success rate (95%-97.5%), block-related pain scores, vascular puncture, and paresthesia. Compared with the supraclavicular and infraclavicular approaches, ultrasound-guided AXBs required a higher number of needle passes (6.1 [SD, 2.0] vs 2.0-2.6 [SD, 1.1-1.8]; both P < or = 0.001), a longer needling time (7.4 mins [SD, 2.2 mins] vs 4.9-5.5 mins [SD, 1.9-4.2 mins]; both P < or = 0.016), and a longer performance time (8.5 mins [SD, 2.3 mins] vs 6.0-6.2 mins [SD, 2.1-4.5 mins]; both P < or = 0.008). Supraclavicular blocks resulted in a higher rate of Horner syndrome (37.5% vs 0%-5%; both P < 0.001).

CONCLUSION

Adjunctive ultrasonography results in similar success rates, total anesthesia-related times, and block-related pain scores for the SCB, ICB, and AXB.

Patient anxiety and conscious surgery

The amount of surgery undertaken on the conscious patient is increasing. However, many patients are anxious and resistant to such surgery. Patients (n = 214) were surveyed to determine their related apprehensions. Being awake, feeling or seeing the body cut open and experiencing pain all increased anxiety. The potential for insufficient information provision was also a source of concern. Formal management of intraoperative apprehension may help limit anxiety and expel apparent misapprehensions.

Conscious surgery: influence of the environment on patient anxiety

AIMS

This paper is a report of a study: (i) to investigate anxiety arising from the experience of the clinical environment during surgery under local/regional anaesthesia and (ii) to uncover the specific aspects patients find anxiety provoking and possibly dissuade them from opting for such anaesthesia.

BACKGROUND

Operating theatre staff have focused historically on conducting safe, efficient surgery with unconscious patients and not primarily on the care of 'awake' patients. However, with the rise in day surgery, the volume of surgery performed under local or regional anaesthesia is increasing.

METHOD

As part of a larger study investigating anxiety in elective day surgery, a questionnaire was given to 523 patients on the day of surgery to adult patients undergoing surgery with local or regional anaesthesia between 2005 and 2007. They were asked to return this by mail 24-48 hours following surgery and 214 completed questionnaires were returned (response rate 41%).

FINDINGS

The experience of being awake, possibly feeling the surgeon's touch, seeing their body cut open or surgery being more painful than expected were anxiety-provoking aspects. Using factor analysis, 'intra-operative apprehension', 'anaesthetic information provision' and 'health control' were identified as central features. Multiple regression showed that apprehension associated with the intra-operative experience and anaesthetic information provision were statistically significantly associated with an increase in overall level of anxiety.

CONCLUSION

Focusing care on managing the intra-operative experience and providing anaesthetic information in advance might help limit anxiety and expel the apparent misapprehensions associated with conscious surgery.

Ultrasound-guided peripheral nerve blocks: what are the benefits?

BACKGROUND

Use of ultrasound by anaesthesiologists performing regional blocks is rapidly gaining popularity. The aims of this review were to summarize and update accumulating evidence on ultrasound-guided nerve blocks, with an emphasis on the clinical relevance of the results and to critically appraise changing standards in regional anaesthesia.

METHODS

A search of MEDLINE and EMBASE (1966 to 31 December 2007) was conducted using the following free terms: 'ultrasound and regional anesthesia', 'ultrasound and peripheral block' and 'ultrasound and nerve and block'. These were combined with the MESH terms 'nerve block' and 'ultrasonography'. The following limits were applied: studies with abstracts, only in humans, published in core clinical journals. Trial type: meta-analysis, randomized-controlled trial and clinical trial.

RESULTS

When peripheral nerves are adequately imaged by ultrasound, the concomitant use of nerve stimulation offers no further advantage. However, several studies reported problems with obtaining satisfactory images in some patients. Ultrasound guidance significantly shortened the block performance time and/or reduced the number of needle passes to reach the target in all comparative studies. The occurrence of paraesthesia during block performance was also reduced, but not the incidence of short-lasting post-operative neuropraxia. The frequency of accidental vascular punctures may be lower, but the data are contradictory. Block onset time was significantly shortened. Block duration was longer in children, but not in adults. Ultrasound also allowed dose reduction of the local anaesthetic (LA).

CONCLUSIONS

Ultrasound guidance shortens the block performance time, reduces the number of needle passes and shortens the block onset time. Blocks may be performed using lower LA doses.

Sedation and regional anaesthesia in the adult patient

This review discusses sedation for regional anaesthesia in the adult population. The first section deals with general aspects of sedation and shows that the majority of patients receiving sedation for regional anaesthesia are satisfied and would choose it again. Methods of assessing the level of sedation are discussed with emphasis on clinical measures. The pharmacology of the drugs involved in sedation is discussed, with propofol and remifentanil appearing to be the combination of choice for sedation in regional anaesthesia. The techniques for administering sedation are discussed and replacement of the traditional repeated boluses or continuous infusion with pharmacokinetic and patient-controlled systems is supported. Patient satisfaction studies suggest that patient-controlled systems are preferred.

Eutectic mixture of local anesthetic (EMLA) decreases pain during humeral block placement in nonsedated patients

BACKGROUND

We evaluated the potential role of an euctectic mixture of local anesthetic (EMLA) cream application before performing midhumeral block.

METHODS

Sixty patients undergoing surgery distal to the elbow amenable to a humeral block were prospectively recruited for the study. The patients were randomly allocated to 1 of 3 groups: Group E: topical EMLA cream 60 min before block plus 2 mL IV normal saline 5 min before procedure; Group P: topical sham cream plus 2 mL IV normal saline, and Group S: topical sham cream plus 0.1 microg/kg of sufentanil in 2 mL solution IV. Pain experienced during skin puncture, and overall pain for the whole procedure were rated using a 100-mm visual analog scale (0: no pain to 100: worst pain).

RESULTS

Patients in Group E experienced less pain compared with those in Groups P and S (5 +/- 3 mm vs 33 +/- 20 mm and 30 +/- 18 mm, respectively, P < 0.0001). The pain experienced throughout the complete humeral block was more substantial in Group P than in Group E (P = 0.01).

CONCLUSION

The patients who received EMLA cream had less pain with needle puncture as well as throughout the performance of humeral block.

Peripheral nerve blocks for anaesthesia and postoperative analgesia

PURPOSE OF REVIEW

Perioperative analgesia is a major concern for the patient and for the anesthesiologist, whose task is to avoid pain and all related complications on immediate outcome and healing. Regional anesthesia, alone or combined with general anesthesia, is becoming a preferred technique in a variety of surgical procedures. There is increasing interest in peripheral nerve blocks, single or continuous, mainly for perioperative treatment of unilateral surgery. Specificity of analgesic area combined with decreased complications, including spinal or epidural hematoma, urinary retention, or hemodynamic alterations, are advantages of the peripheral nerve block over more central neural blocks.

RECENT FINDINGS

Insertion of catheters near neural plexuses or in the vicinity of single nerves are being continuously developed and improved. The appearance of new techniques and devices is increasing. Percutaneous electrode guidance, ultrasonographic localization of neural structures, and the use of stimulating catheters represent the newest advances in this area. Use of enantiomeric local anesthetic drugs permits a safer and wider range of postoperative treatment, which includes continuous analgesia administered in the patient's home. Use of patient-controlled analgesia, through electronic or elastomeric pumps, is recommended for postoperative pain control. Peripheral nerve block is the standard for anesthesia or analgesia in ambulatory surgery. Complications of the technique have been examined in large clinical studies which have recently been published. Results of such studies highlight the effectiveness and safety of peripheral blocks. These results have given new strength to arguments for regional anesthesia and analgesia and led to the increase in popularity of regional techniques. The articles considered below have, in summary, the main purpose of enhancing safety, as well as dissemination and education regarding regional anesthetic techniques.

SUMMARY

Possibilities afforded by the use of peripheral nerve blocks mainly consist of prolonged analgesia, selective area of action, and fewer collateral effects when compared with general anesthesia or more central neural blockade. Introduction of new devices and new techniques are increasing, as evidenced by the large number of studies which have appeared in the literature during the past year.

Patient comfort during regional anesthesia

Regional anesthesia has many advantages, which include low cost, ease of administration, and avoidance of risks associated with general anesthesia. Injection of local anesthetic via a needle as part of a regional anesthetic technique can be a stressful experience. The goal is to produce a relaxed patient who is comfortable and cooperative throughout the duration of surgery. The topics of regional anesthetic techniques, drug combinations, and adjunct measures such as sedation have been described extensively in the literature. The issue of patient comfort has not been reviewed in its entirety. This review seeks to collate known information in a systematic format and provide a framework for patient comfort during regional anesthesia.

USE OF A NERVE LOCATOR TO FACILITATE ADMINISTRATION OF MANDIBULAR NERVE BLOCKS IN CROCODILIANS

As part of a clinical workup of dental problems in a large crocodilian collection, mandibular nerve blocks were performed in the animals. A nerve locator was used to facilitate placement of the nerve blocks in American alligators (Alligator mississippiensis), Yacare caiman (Caiman yacare), and a dwarf crocodile (Osteolaemus tetraspis). Provision of analgesia is a frequently underused aspect of patient care in reptiles. Use of a nerve stimulator provides an objective measurement of nerve conduction blockade and may be useful in exotic species in which anatomic landmarks for nerve block placement are not well established.

A comparison between double-injection axillary brachial plexus block and midhumeral block for emergency upper limb surgery

In this prospective and randomized study, we compared a double-injection axillary (median and radial nerves) block with a midhumeral block in 90 patients undergoing emergency upper limb surgery. Time to perform the block, success rate, and patient tolerance were evaluated. The time to perform the block was 5 min longer in the midhumeral group. The success rate was similar in both groups (80% and 91% in groups axillary and midhumeral respectively), except for the musculocutaneous nerve. Patient tolerance was better in the axillary group. Double-injection axillary brachial plexus block is superior to midhumeral block for emergency hand surgery.

Peripheral Nerve Block Techniques for Ambulatory Surgery

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

A comparison of the vertical infraclavicular and axillary approaches for brachial plexus anaesthesia

BACKGROUND

This prospective, randomized study compared the efficacy of the vertical infraclavicular and axillary approaches using a single injection blockade of the brachial plexus. The primary endpoint was complete blockade in dermatomes C5-Th1, while secondary endpoints included onset time, motor block, block performance time, surgical success rate, patient satisfaction, and side-effects/complications.

METHODS

Sixty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the forearm or hand received either a vertical infraclavicular (n = 30) or an axillary block (n = 30). A single injection of 0.5 ml/kg ropivacaine 7.5 mg/ml was made after electrolocalization of nerve fibres corresponding to the median nerve at maximum 0.5 mA (2 Hz, 0.1 ms). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30 and 60 min after the local anaesthetic injection. A complete block was defined as analgesia in all dermatomes (C5-Th1) at 60 min post-injection.

RESULTS

The vertical infraclavicular approach provided complete blockade in 29 patients (97%) and the axillary approach in 23 patients (77%). Analgesia in C5-C6 dermatomes and corresponding motor block occurred significantly more frequently in the vertical infraclavicular approach, which also had the shortest onset time. Block procedure was quicker in the axillary approach. Side-effects were similar in both groups, and there were no permanent sequelae. Patient satisfaction was equally high in both groups.

CONCLUSION

The vertical infraclavicular approach provides a more complete block than the axillary approach when using a single injection technique and equal volumes/doses of local anaesthetic.

Intraoperative Bier's block as supplement to insufficient axillary block anesthesia in upper extremity surgery

The authors reviewed 52 patients who underwent Bier's block, as supplementary anesthesia for insufficient axillary block in upper extremity surgical procedures. Prior to proceeding to the Bier's block, the mean value of pain using the visual optical analogue scale (VAS) was 7.0. In 48 of the patients supplementation with the Bier's block was sufficient (mean VAS score of 1.0) and all patients were comfortable throughout the procedure. In the remaining four patients supplementation with narcotics and sedatives via the other i.v. line was required. Intraoperative Bier's block provides a safe and effective alternative way of successfully compensating for an insufficient axillary block in upper extremity surgical procedures.

Infraclavicular block causes less discomfort than axillary block in ambulatory patients

BACKGROUND

This randomized study was designed to compare discomfort caused by axillary or infraclavicular blocks in ambulatory patients. We identified which of the three block components, needle passes, local anesthetic (LA) injections, and electrical stimulations, is most painful and quantified pain intensity on a visual analog scale (VAS 0-100). We also assessed onset and quality of analgesia, adverse events and patients' acceptance.

METHODS

Eighty patients were studied. In axillary group-A, four LA injections were made after stimulating median, musculocutaneous, ulnar and radial nerves. In infraclavicular group-I, the whole LA volume was injected after stimulating median or ulnar or radial nerves. Patients were ready for surgery when they had analgesia/anesthesia distal to the elbow.

RESULTS

Median intensity of block discomfort was 22 in A group and 10 in I group (P < 0.01). There was no difference in distribution of the most painful block components between the groups. Block performance times were 4 min in I group and 7 min in A group (P < 0.01). Block onset times were 18 min in A group and 20 min in I group (NS). There was one block failure in I group. Three patients in A group and five in I group required supplementary blocks (NS). Transient adverse events occurred in 14 A-group and two I-group patients (P<0.01). Thirty-seven I-group and 33 A-group patients were satisfied with the block (NS).

CONCLUSIONS

Infraclavicular block by single injection caused less discomfort and fewer adverse events than axillary block by multiple injections. Block effectiveness, onset time and patients' acceptance were similar.

Peripheral Nerve Blocks and Continuous Catheter Techniques

Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.