Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks

Effects of Ultrasound-Guided Lower Extremity Nerve Blocks for Below-Knee Procedures in the Emergency Department of a Tertiary Care Hospital, Central Gujarat

Background and objectives Ultrasound-guided femoral and popliteal sciatic nerve blocks are useful adjuncts for many below-knee procedures like debridement, amputation, etc. The objectives of the study were to find the efficacy and feasibility of the ultrasound-guided combined femoral and popliteal sciatic nerve block for below-knee procedures in the Emergency Medicine Department (ED). Methodology This prospective clinical study was carried out over three months in ED. A total of 30 patients undergoing below-knee procedures were included in the study. Femoral and popliteal sciatic nerve blocks were administered to each patient using the high-frequency linear ultrasound probe by emergency physicians trained in ultrasound. The effect of blocks, amount of local anesthetic (LA) used, duration of the procedure, and post-block analgesia were recorded. Patients were monitored for possible complications, if any. Data were entered and analyzed using a Microsoft Excel worksheet. Results The average volume of LAs required was around 34.5 cc for both blocks combined. No complications like vascular puncture or nerve injury were reported during the study. The time taken to complete the procedure was around 33 minutes, and the average time to achieve sensory block was around 9 minutes after completing the procedure. Conclusions An ultrasound-guided combined femoral and popliteal sciatic nerve block is an effective and feasible procedure and thus should be considered in ED for below-knee procedures.

Peripheral Nerve Stimulator Versus Ultrasound-Guided Femoral Nerve Block for Knee Arthroscopy Procedures: A Randomized Controlled Trial

Background

Femoral nerve block (FNB) provides effective analgesia and is a widely used technique for postoperative pain relief for orthopedic procedures on lower limbs. This study aims to compare the efficacy of ultrasonography (USG) versus peripheral nerve stimulator (PNS)-guided FNB in knee arthroscopic procedures.

Methodology

This randomized comparative study included two study groups with 30 participants in each group who were given FNB with either PNS or USG for knee arthroscopic procedures following spinal anesthesia. The study evaluated the number of needle repositioning, the time taken for performing the block, the efficacy of postoperative analgesia based on the duration of the block, and patient satisfaction.

Results

The number of needle repositioning and time taken to finish the procedure using USG was lower compared to the group using PNS (p < 0.001). The duration of the block was comparable in both groups (p = 0.584). Patients were satisfied with both techniques and responded as either very good or outstanding and chose neither as inferior (p = 0.310).

Conclusions

Both techniques have equal efficacy concerning the duration of the effect of the block and patient satisfaction. However, the procedural time and number of needle repositioning were significantly less in the group where USG was used for the block.

Effects of pericapsular nerve group (PENG) block on postoperative recovery in elderly patients with hip fracture: study protocol for a randomised, parallel controlled, double-blind trial

INTRODUCTION

Hip fracture is a common and serious emergency in the elderly, and it is associated with severe pain, significant morbidity and mortality. The use of peripheral nerve block can relieve pain effectively and reduce opioid requirements, which may accelerate patient's recovery. The pericapsular nerve group (PENG) block has been found to provide an effective blockade to the hip joint with a potential motor-sparing effect, so we hypothesised that the PENG block may be an effective tool to enhance the recovery in elderly patients after hip fracture surgery.

METHODS AND ANALYSIS

This study is a single-centred, randomised, parallel controlled, double-blind trial. A total of 92 elderly patients scheduled for hip fracture surgery will be divided into two groups at random to receive either ultrasound-guided femoral nerve block or ultrasound-guided PENG block. The primary outcome will be to compare the Quality of Recovery-15 scores at 24 hours postoperatively between the two groups. The secondary outcomes will include measuring and comparing the strength of the quadriceps, the visual analogue scale at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilisation and complications.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (reference K2020-110). The results of this study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100042341.

Ultrasound in paediatric anaesthesia - A comprehensive review

The use of ultrasound is becoming more widespread in anaesthesia. In this review, we discuss the use of ultrasound in various aspects of paediatric anaesthesia and how it can be used to assist diagnostic and therapeutic interventions and the evidence available. We explore the use of ultrasound as an adjunct for regional anaesthesia, vascular access, airway management, bedside cardiac, pulmonary and abdominal imaging and intracranial pressure monitoring.

Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis

Background

Arteriovenous fistulae (AVF) are the hemodialysis access modality of choice for patients with end-stage renal disease. However, they have a high early failure rate. Good vascular access is essential to manage long-term hemodialytic treatment, but some anesthesia techniques directly affect venous diameter as well as intra- and post-operative blood flow. The main purpose of this meta-analysis was to compare the results of regional and local anesthesia (RA and LA) for arteriovenous fistula creation in end-stage renal disease.

Methods

We conducted a systematic review and meta-analysis to synthesize evidence from 7 randomized controlled trials (565 patients) and 1 observational study (408 patients) with the aim of evaluating the safety and efficacy of RA versus LA in surgical construction of AVF.

Results

Pooled data showed that RA was associated with higher primary patency rates than LA (odds ratio [OR], 1.88; 95% confidence interval [CI]: 1.24–2.84; P = 0.003; I² = 31%). Additionally, brachial artery diameter was significantly increased in the RA versus LA group (mean difference [MD], 0.83; 95% CI: 0.75–0.92; P < 0.001; I² = 97%) and the need for intra- as well as post-operative pain killers was significantly less (RA, P = 0.0363; LA, P = 0.0318). Moreover, operation duration was significantly reduced using RA versus LA (MD, − 29.63; 95% CI: − 32.78 - -26.48; P < 0.001; I² = 100%).

Conclusions

This meta-analysis suggests that RA is preferable to LA in patients with end-stage renal disease in guaranteeing AVF patency and increasing brachial artery diameter.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis

BACKGROUND

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients.

METHODS

Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence.

RESULTS

We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty.

CONCLUSIONS

The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

Ultrasound-guided versus low dose computed tomography scanning guidance for lumbar facet joint injections: same accuracy and efficiency

BACKGROUND

The purpose of this study was to investigate the feasibility, accuracy and efficiency of the facet joint injections in the lumbar spine by ultrasound guided versus lose dose computed tomography (CT) guidance.

METHODS

First the examination on the joint space of the facet joints of the lumbar spine was obtained by the ultrasound in 10 patients. Second forty patients were randomized assigned into two groups: ultrasound group and low dose CT group. Comparison was made in the clinical efficiency between the ultrasound-guided group and CT group. The feasibility, accuracy and efficiency of the ultrasound-guided lumbar facet joint injections were also evaluated.

RESULTS

A total of 88 lumbar facet joints from L1 to S1 were clearly visualized in the 10 patients. Both the ultrasound and the CT measurements showed the same average depth and lateral distance to the reference point (P > 0.05). And 86.5% of the facet joint injections (64/74) were correctly performed under the ultrasound guidance in the first time. The exact placement of the needle tips was evaluated by CT. After the lumbar facet joint injections, the clinical efficiency was almost the same in the ultrasound-guided group as in the CT group.

CONCLUSIONS

The lumbar facet joint space can be accurately demonstrated by ultrasound. The ultrasound-guided facet joint injection in the lumbar spine obtained almost the same satisfactory feasibility, accuracy and clinical efficiency compared with low dose CT. Ultrasound technique could provide the real-time monitoring.

TRIAL REGISTRATION

This study was registered on Chinese Clinical Trial Registry ( ChiCTR1800018819 , retrospective registered on 11/10/2018).

[Ultrasound-guided interventions on the peripheral nervous system]

CLINICAL/METHODICAL ISSUE

Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage.

METHODICAL INNOVATIONS

Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible.

ACHIEVEMENTS

This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described.

PRACTICAL RECOMMENDATIONS

Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.

Ultrasound-Guided Femoral Nerve Block to Facilitate the Closed Reduction of a Dislocated Hip Prosthesis

Prosthetic hip dislocation is a common but unfortunate complication in patients who have undergone total hip arthroplasty. Successful closed reduction in the emergency department leads to a reduced length of stay and rate of hospitalization.1,2 The use of regional anesthesia by femoral nerve block represents a novel approach for controlling pain in patients with hip pathologies.3 Ultrasound-guided approaches have been used with great success for controlling pain in patients with hip fractures.4,5 Here we report the case of a 90-year-old male who presented with a dislocated hip prosthesis, which was subsequently corrected with closed reduction following delivery of regional anesthesia to the femoral nerve under ultrasound guidance. To our knowledge, this represents the first reported use of an ultrasound-guided femoral nerve block to facilitate closed reduction of a dislocated prosthetic hip, and highlights a novel approach that avoids the use of procedural sedation in an elderly patient.

Peripheral nerve blocks for hip fractures

BACKGROUND

Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.

OBJECTIVES

This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.

MAIN RESULTS

We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I² = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I² = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I² = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I² = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).

AUTHORS' CONCLUSIONS

High-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).

Implementation of clinical practice changes by experienced anesthesiologists after simulation-based ultrasound-guided regional anesthesia training

Background

Anesthesiologists who have finished formal training and want to learn ultrasound-guided regional anesthesia (UGRA) commonly attend 1 day workshops. However, it is unclear whether participation actually changes clinical practice. We assessed change implementation after completion of a 1 day simulation-based UGRA workshop.

Methods

Practicing anesthesiologists who participated in a 1 day UGRA course from January 2012 through May 2014 were surveyed. The course consisted of clinical observation of UGRA procedures, didactic lectures, ultrasound scanning, hands-on perineural catheter placement, and mannequin simulation. The primary outcome was the average number of UGRA blocks per month reported at follow-up versus baseline. Secondary outcomes included preference for ultrasound as the nerve localization technique, ratings of UGRA teaching methods, and obstacles to performing UGRA.

Results

Survey data from 46 course participants (60% response rate) were included for analysis. Participants were (median [10th–90th percentile]) 50 (37–63) years old, had been in practice for 17 (5–30) years, and were surveyed 27 (10–34) months after their UGRA training. Participants reported performing 24 (4–90) blocks per month at follow-up compared to 10 (2–24) blocks at baseline (P < 0.001). Compared to baseline, more participants at follow-up preferred ultrasound for nerve localization. The major obstacle to implementing UGRA in clinical practice was time pressure.

Conclusions

Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.

Focused Training for Humanitarian Responders in Regional Anesthesia Techniques for a Planned Randomized Controlled Trial in a Disaster Setting

Background:Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Médecins Sans Frontières (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting.

Methods:Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers.

Results:Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively.

Discussion:Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.

Regional Anesthesia for Painful Injuries after Disasters (RAPID): study protocol for a randomized controlled trial

Background

Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting.

Methods/design

The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction.

Discussion

Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma.

Trial registration

ClinicalTrials.gov (NCT02698228), registered on 16 February 2016.

Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures

OBJECTIVES

To compare pain relief between patients with intracapsular and extracapsular hip fractures who received an ultrasound-guided femoral nerve block (USFNB).

DESIGN

A multicenter, prospective, randomized, clinical trial.

SETTING

The study was conducted in the emergency departments of 3 academic hospitals located in New York City.

SUBJECTS

Patients aged ≥60 years presenting to the emergency department with hip fracture.

METHODS

A subgroup analysis from a larger data set was conducted of patients with intracapsular and extracapsular hip fractures who received an USFNB. We compared pain scores at baseline and then at 2 and 3 hours after the nerve block was performed, and also assessed pain relief at 2 and 3 hours.

RESULTS

Seventy-seven patients were randomized to receive USFNB, of which 68 had follow-up data at 2 and 3 hours and were included in the data analysis. Thirty-one were diagnosed with intracapsular and 37 with extracapsular hip fractures. In both groups, reductions in pain scores were clinically and statistically significant. In the intracapsular group, mean pain scores decreased from 6.23 to 3.81 (P < .0001) at 2 hours and from 6.23 to 3.87 (P < .0001) at 3 hours. In the extracapsular group, mean pain scores decreased from 6.62 to 3.89 (P < .0001) at 2 hours and from 6.62 to 3.46 (P < .0001) at 3 hours. These differences were similar between the extracapsular and intracapsular groups at 2 hours (P = .92) and at 3 hours (P = .58), thus demonstrating similar reductions in pain in the 2 groups. The differences in pain relief between the intracapsular and extracapsular groups were also similar: 1.61 (confidence interval [CI], 1.14-2.08) vs 1.35 (CI, 0.96-1.75) at 2 hours (P = .39) and 1.68 (CI, 1.21-2.15) vs 1.38 (CI, 0.89-1.87) at 3 hours (P = .38).

CONCLUSION

Ultrasound-guided femoral nerve block was equally effective in reducing pain for patients with both intracapsular and extracapsular hip fractures.

Ultrasound guidance for upper and lower limb blocks

BACKGROUND

Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014.

OBJECTIVES

The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks

SEARCH METHODS

In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies.

MAIN RESULTS

We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block.

AUTHORS' CONCLUSIONS

There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.

Ultrasound guidance for upper and lower limb blocks

BACKGROUND

Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014.

OBJECTIVES

The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks

SEARCH METHODS

In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies.

MAIN RESULTS

We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block.

AUTHORS' CONCLUSIONS

There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.

Ultrasound-guided pulse-dose radiofrequency: treatment of neuropathic pain after brachial plexus lesion and arm revascularization

Neuropathic pain following brachial plexus injury is a severe sequela that is difficult to treat. Pulsed radiofrequency (PRF) has been proved to reduce neuropathic pain after nerve injury, even though the underlying mechanism remains unclear. This case report describes the use of ultrasound-guided PRF to reduce neuropathic pain in a double-level upper extremity nerve injury. A 25-year-old man who sustained a complete left brachial plexus injury with cervical root avulsion came to our attention. Since 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb. No pain relief was obtained by means of surgery, rehabilitation, and medications. Ultrasound-guided PRF was performed on the ulnar nerve at the elbow level. The median nerve received a PRF treatment at wrist level. After the treatment, the patient reported a consistent reduction of pain in his hand. We measured a 70% reduction of pain on the VAS scale. PRF treatment allowed our patient to return to work after a period of absence enforced by severe pain. This case showed that PRF is a useful tool when pharmacological therapy is inadequate for pain control in posttraumatic neuropathic pain.

Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department

Objective

We examined the pain-relieving effect of ultrasound-guided regional anesthesia performed by emergency physicians on elderly hip fracture patients.

Methods

This study is a prospective, non-randomized, case-control study. The subjects were patients older than 65 years who visited the emergency department with a hip fracture. After we obtained informed consent, two emergency physicians performed an ultrasound-guided three-in-one femoral block using 20 mL of 0.5% bupivacaine. The pain score was measured just before regional anesthesia, and 0.25, 0.5, 1, 2, 3, and 4 hours after the procedure. Another group of patients was given multiple doses of morphine to control the pain. We compared the change in pain score and the development of adverse reactions between the two groups.

Results

A total of 47 patients were enrolled in this study, of which 25 were given regional anesthesia. Successful pain control (pain score<4) was significantly higher in the regional anesthesia group (96.0% vs. 40.9%; P<0.001). The decrease in pain score was significantly higher in the regional anesthesia group (7 [interquartile range, 6 to 7] vs. 4 [interquartile range, 3 to 5]; P< 0.001). The only adverse reaction observed was mild nausea in 4 patients (1 out of 25 from the regional anesthesia group and 3 out of 22 from the morphine group).

Conclusion

Ultrasound-guided regional anesthesia administered by emergency physicians treating elderly hip fracture patients provided faster pain relief and a larger decrease in pain than conventional intravenous injections of morphine.

Ultrasound as a screening tool for performing caudal epidural injections

Background:

The caudal approach to the epidural space has been used for decades to treat low back pain caused by lumbosacral root compression. The use of fluoroscopy during epidural steroid injection is the preferred method for placing the needle more accurately in the sacral hiatus, but it carries the risk of radiation hazard.

Objectives:

The aim of the study was to assess the anatomical structure of the sacral hiatus and the feasibility of caudal epidural injections under ultrasound guidance.

Patients and Methods:

Two hundred and forty patients (male = 100, female = 140) with low back pain and sciatica who were candidates for caudal epidural injection were enrolled into this study. Ultrasound images of the sacral hiatus and bilateral cornua were obtained by a real-time linear array ultrasound transducer. The distance between bilateral cornua and the anterior and posterior wall of the sacrum were measured at the base (sacral hiatus). Under the guide of ultrasonography, we defined the injection successful if turbulence of medication fluid was observed in the sacral canal, but correct placement of the needle and injectant was confirmed on fluoroscopic view as the gold standard technique.

Results:

The epidurogram showed that the injection was successful in 230 of the 240 patients (95.8%). In eight patients, the injection was not in the correct place in the sacral canal. The sacral hiatus could not be identified by ultrasound images in only two patients who had a closed sacral hiatus identified by fluoroscopy. The mean distance of the sacral hiatus was 4.7 ± 1.7 mm and the mean distance between bilateral cornua was 18.0 ± 2.8 mm. The mean duration of the procedure was 10.8 ± 6.8 minutes. No major complication was observed in the next month.

Conclusions:

In conclusion, ultrasound could be used as a safe, fast and reliable modality to observe the anatomic variation of the sacral hiatus and to perform caudal epidural injections.

Ultrasound-guided anterior axilla musculocutaneous nerve block

PURPOSE

This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla.

MATERIALS AND METHODS

Twenty patients (7 males and 13 females; mean age, 35 years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated.

RESULTS

Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication.

CONCLUSION

The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

Peridural Anesthesia or Ultrasound-Guided Continuous 3-in-1 Block: Which Is Indicated for Analgesia in Very Elderly Patients With Hip Fracture in the Emergency Department?

PURPOSE

The aim of our study was to investigate the clinical relevance of preoperative acute pain management and cardiovascular stability by ultrasound-guided continuous 3-in-1 nerve block in very elderly patients with hip fracture when compared to epidural anesthesia (PDA).

METHODS

To study the analgesic effect, we enrolled 37 very elderly patients with hip fractures, of whom 3 patients with dementia had to be excluded. Thus, 34 patients were randomized to 1 of the 3 groups: group A (ultrasound-guided continuous 3-in-1 block, bupivacaine; n = 10, dropout rate: 0), group B (PDA, bupivacaine; n = 14, dropout rate: 8), and group C (systemic pain therapy, piritramide/paracetamol; n = 10, dropout rate: 0). Pain intensity was assessed preoperatively and up to 24 hours postoperatively using a visual analog scale, verbal rating scale, analgesic consumption, scale of well-being, and cardiocirculatory parameters (eg, serum troponin T).

RESULTS

Our data show that in the preoperative period both regional anesthesia (RA) procedures (analgesia responders after 1 hour: 86.7% and 100%; P = .001) were superior to systemic analgesia (analgesia responders: 46.7%), and the rescue medication requirement in the 2 RA groups was significantly lower (P = .02). Serum troponin T level increased only in the systemic analgesia group (P = .04). In the emergency department, the disadvantage of PDA in geriatric patients with hip fracture was the fact that procedures were more complex, resulting in a high dropout rate (57.1%). The use of PDA has to be critically discussed for ethical concerns.

CONCLUSION

In the specific situation of acute hospital admission, the ultrasound-guided continuous 3-in-1 block appears to be indicated as a stress-free means of providing adequate preoperative pain relief in very elderly patients with hip fracture. However, these findings should be corroborated by studies involving larger numbers of patients.

Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians

Background:

Patients require procedural sedation and analgesia (PSA) for the treatment of acute traumatic injuries. PSA has complications. Ultrasound (US) guided peripheral nerve block is a safe alternative.

Aim:

Ultrasound guided nerve blocks for management of traumatic limb emergencies in Emergency Department (ED).

Setting and Design:

Prospective observational study conducted in ED.

Materials and Methods:

Patients above five years requiring analgesia for management of limb emergencies were recruited. Emergency Physicians trained in US guided nerve blocks performed the procedure.

Statistical analysis:

Effectiveness of pain control, using visual analogue scale was assessed at baseline and at 15 and 60 minutes after the procedure. Paired t test was used for comparison.

Results:

Fifty US guided nerve blocks were sciatic- 4 (8%), femoral-7 (14%), brachial- 29 (58%), median -6 (12%), and radial 2 (4%) nerves. No patients required rescue PSA. Initial median VAS score was 9 (Inter Quartile Range [IQR] 7-10) and at 1 hour was 2(IQR 0-4). Median reduction in VAS score was 7.44 (IQR 8-10(75%), 1-2(25%) (P=0.0001). Median procedure time was 9 minutes (IQR 3, 12 minutes) and median time to reduction of pain was 5 minutes (IQR 1,15 minutes). No immediate or late complications noticed at 3 months.

Conclusion:

Ultrasound-guided nerve blocks can be safely and effectively performed for upper and lower limb emergencies by emergency physicians with adequate training.

Ultrasound guided versus CT-controlled pararadicular injections in the lumbar spine: a prospective randomized clinical trial

BACKGROUND AND PURPOSE

Injection therapies play a major role in the treatment of lower back pain and are to date performed mainly under CT- or fluoroscopic guidance. We conducted this study to evaluate the accuracy, time savings, radiation doses, and pain relief of US-guided pararadicular injections versus CT-controlled interventions in the lumbar spine in a prospective randomized clinical trial.

MATERIALS AND METHODS

Forty adult patients were consecutively enrolled and assigned to a US or CT group. US-guided pararadicular injections were performed on a standard US device by using a broadband curved-array transducer (9-4 or 5-1 MHz). In the in-plane technique, the needle was advanced through the respective segmental intertransverse ligament. The needle tip position was verified by CT. The CT-guided approaches were performed under standardized procedures by using the CT-positioning laser function.

RESULTS

The accuracy of US-guided interventions was 90%. The mean time to final needle placement in the US group was 4.0 ± 1.8 minutes, and in the CT group, 7.6 ± 2.1 minutes. The mean radiation doses, including CT confirmation for study purposes only, were 20.3 ± 9.0 mGy cm for the US group and 42.6 ± 36.1 mGy cm for the CT group. Both groups showed the same significant pain relief (P < .05) without relevant "intermethodic" differences of pain relief (P > .05).

CONCLUSIONS

US-guided pararadicular injections show a therapeutic effect similar to that in the time-consuming, expensive, ionizing CT or fluoroscopically guided pararadicular injections and result in a significant reduction of procedure time expenditure and avoidance of radiation.

The role of continuous peripheral nerve blocks

A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.

Clinical comparisons of 0.5% and 0.375% levobupivacaine for ultrasound-guided axillary brachial plexus block with nerve stimulation

Background

In an axillary brachial plexus block (ABPB), where relatively large doses of local anesthetics are administered, levobupivacaine is preferred due to a greater margin of safety. However, the efficacy of levobupivacaine in ABPB has not been studied much. We performed a prospective, double-blinded study to compare the clinical effect of 0.375% levobupivacaine with 0.5% levobupivacaine for ultrasound (US)-guided ABPB with nerve stimulation.

Methods

Forty patients undergoing elective upper limb surgery were randomized into two groups: Group I (0.375% levobupivacaine) and Group II (0.5% levobupivacaine). All four main terminal nerves of the brachial plexus were blocked separately with 7 ml of levobupivacaine using US guidance with nerve stimulation according to study group. A blinded observer recorded the onset time for sensory and motor block, elapsed time to be ready for surgery, recovery time for sensory and motor block, quality of anesthesia, patient satisfaction and complications.

Results

There were no significant differences in the time to find nerve locations, time to perform block and number of skin punctures between groups. Insufficient block was reported in one patient of Group I, but no failed block was reported in either group. There were no differences in the onset time for sensory and motor block, elapsed time to be ready for surgery, patient satisfaction and complications.

Conclusions

0.375% levobupivacaine produced adequate anesthesia for ABPB using US guidance with nerve stimulation, without any clinically significant differences compared to 0.5% levobupivacaine.

Ultrasound-guided fascia iliaca compartment block in pediatric patients using a long-axis, in-plane needle technique: a report of three cases

Ultrasound guided fascia iliaca compartment block (FICB) has not been previously described in pediatric patients. Reported here is an ultrasound guided long axis, in-plane needle technique used to perform FICB in three pediatric patients undergoing hip or femur surgery. Postoperative assessment revealed nerve blockade of the lateral femoral cutaneous, femoral, and obturator nerves or no requirement for narcotics in the PACU. FICB using this ultrasound guided technique was easy to perform and provided postoperative analgesia for hip and femur surgical procedures within the presumed distribution of the lateral femoral cutaneous, femoral, and obturator nerves.

Ultrasound guidance for deep peripheral nerve blocks: a brief review

Nerve stimulation and ultrasound have been introduced to the practice of regional anesthesia mostly in the last two decades. Ultrasound did not gain as much popularity as the nerve stimulation until a decade ago because of the simplicity, accuracy and portability of the nerve stimulator. Ultrasound is now available in most academic centers practicing regional anesthesia and is a popular tool amongst trainees for performance of nerve blocks. This review article specifically discusses the role of ultrasonography for deeply situated nerves or plexuses such as the infraclavicular block for the upper extremity and lumbar plexus and sciatic nerve blocks for the lower extremity. Transitioning from nerve stimulation to ultrasound-guided blocks alone or in combination is beneficial in certain scenarios. However, not every patient undergoing regional anesthesia technique benefits from the use of ultrasound, especially when circumstances resulting in difficult visualization such as deep nerve blocks and/or block performed by inexperienced ultrasonographers. The use of ultrasound does not replace experience and knowledge of relevant anatomy, especially for visualization of deep structures. In certain scenarios, ultrasound may not offer additional value and substantial amount of time may be spent trying to find relevant structures or even provide a false sense of security, especially to an inexperienced operator. We look at available literature on the role of ultrasound for the performance of deep peripheral nerve blocks and its benefits.

Axillary brachial plexus block

The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance.

A new simplified sonographic approach for pararadicular injections in the lumbar spine: a CT-controlled cadaver study

BACKGROUND AND PURPOSE

Injection therapies play a major role in the treatment of lower back pain and are to date performed mainly under CT or fluoroscopic guidance. The benefits of US-guided instillation procedures have been shown in many studies. We conducted this study to simplify an US-guided approach to the lumbar spinal nerves and to assess the feasibility and preliminary accuracy by means of CT and anatomic dissection.

MATERIALS AND METHODS

Ten US-guided injections at 5 different levels (L1-L5) were performed on 1 embalmed cadaver. Images in 3 sagittal/parasagittal scanning planes were obtained at each lumbar level: 1) the plane of the spinous processes, 2) the plane of the lumbar arches/zygapophyseal-joints, and 3) the plane of the transverse processes. The PAP was then defined by positioning the transducer perpendicularly over the medial part of the respective transverse processes, depicting the hyperechoic intertransverse ligament. In the "in-plane technique," spinal needles were advanced through the respective segmental intertransverse ligament. A solution consisting of a contrast agent and a pigmented dispersion was subsequently injected into the pararadicular compartment. An anatomic dissection of the specimen and CT scans were performed to verify the exact placement of the needle tips and to evaluate fluid dispersion in the punctured compartment.

RESULTS

CT examination confirmed that each needle tip was correctly placed within the intended compartment with sufficient contrast accumulation around the respective proximal segment of the spinal nerve. On each anatomic section, dye was identified in the correct compartment and directly around each targeted spinal nerve with needles shown in the correct position.

CONCLUSIONS

This modified US approach for therapeutic root injections in the lumbar spine by using the intertransverse ligament as a new anatomic landmark allows an easy and correct needle placement within the pararadicular compartment.

Ultrasound-guided supraclavicular brachial plexus block in pediatric patients -A report of four cases-

Supraclavicular brachial plexus blocks are not common in pediatric patients due to the risk of pneumothorax. Ultrasonography is an important tool for identifying nerves during regional anesthesia. Directly visualizing the target nerves and monitoring the distribution of the local anesthetic are potentially significant. In addition, ultrasound monitoring helps avoid complications, such as inadvertent intravascular injection or pneumothorax. This paper reports four cases of pediatric patients who received ultrasound-guided supraclavicular brachial plexus block for upper limb surgery.

Emergency orthogeriatrics: concepts and therapeutic alternatives

Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery.

Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia

PURPOSE

Perineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.

METHODS

Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr(-1); bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.

RESULTS

Forty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was -6.48 (-9.90 - -3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).

CONCLUSION

For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.

Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur

Purpose

Fracture of femur is a painful bone injury, worsened by any movement. This prospective study was performed to compare the analgesic effects of femoral nerve block (FNB) with intravenous (IV) fentanyl prior to positioning patients with fractured femur for spinal block.

Patients and methods

Sixty-four ASA I–III patients aged 18–80 years undergoing surgery for femur fracture were randomized into two groups. Fifteen minutes before spinal block, the FNB group received nerve stimulator-assisted FNB with a mixture of 20 mL bupivacaine 0.5% and 10 mL normal saline 0.9%, and the fentanyl group received two doses of IV fentanyl 0.5 μg/kg with a five-minute interval between doses. Numeric rating pain scores were compared. During positioning, fentanyl in 0.5 μg/kg increments was given every five minutes until pain scores were ≤4.

Results

There were no statistically significant differences between the groups according to pain scores, need for additional fentanyl, and satisfaction with positioning before spinal block.

Conclusion

We were unable to demonstrate a benefit of FNB over IV fentanyl for patient positioning before spinal block. However, FNB can provide postoperative pain relief, whereas side effects of fentanyl must be considered, and analgesic dosing should be titrated based on pain scores. A multimodal approach (FNB + IV fentanyl) may be a possible option.

Ultrasound guidance in regional anesthesia: state of the art review through challenging clinical scenarios

Ultrasound guided regional anesthesia (UGRA) for peripheral nerve blockade is becoming increasingly popular. The advantage of ultrasound technology is that it affords the anesthesiologist the real time ability to visualize neural structures, needle advancement, and local anesthetic spread. Recent data suggest that UGRA generates improved success rates and reductions in performance times in comparison to traditional approaches. Further, the use of ultrasound technology in peripheral nerve blocks has provided insight into needle-nerve interactions, revealing distinct limitations of nerve stimulator techniques. Given that UGRA requires a unique set of skills, formal standards and guidelines are currently being developed by leadership societies in order to foster education and training. This review article, in a case vignette format, highlights important techniques, concepts, and limitations regarding the use of ultrasound to facilitate regional anesthesia. Clinically relevant aspects of ultrasound physics are also discussed.

Ultrasound-guided peripheral nerve blockade

Peripheral nerve blockade (PNB) for orthopedic surgery is usually performed without visual guidance, relying mainly on surface anatomic landmarks and electrical stimulation to localize nerves. Moreover, multiple trial and error attempts to place a needle can frustrate the operator, cause unwarranted pain to the patient, and waste valuable time in the operating room. Inaccurate needle placement and spread of local anesthetic account for most PNB failures, whereas "trial and error" needle manipulations for nerve localization can cause complications. The recent application of ultrasound (US) to PNB affords real-time imaging of the target nerve, needle, and surrounding vasculature, such that needle proximity to the nerve is ensured and vascular puncture avoided. This article reviews the advantages, principles, and techniques of US for the most common types of PNB.

Best evidence topic report. Ultrasound placement of needle in three-in-one nerve block

A short cut review was carried out to establish whether ultrasound placement of three-in-one block is better than placement using a nerve stimulator. 137 papers were found, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block.

Pilot study of neuraxial imaging by ultrasound in infants and children

BACKGROUND

Ultrasonography is becoming an important adjunct in regional anesthesia. Epidural anesthesia may pose significant challenges in infants and children because of difficulties in identifying the epidural space. In addition, epidural catheters are sometimes difficult to advance. The present study was performed to evaluate an optimal ultrasound technique for direct visualization of neuraxial structures in children.

METHODS

A total of 32 infants and children scheduled for minor surgery were prospectively included in a high-resolution ultrasound study. Scans were performed using either a sector or linear probe and views from a longitudinal paramedian, median and transversal angle at lumbar and thoracic levels of the spinal cord were analyzed.

RESULTS

In all children investigated, the linear probe generated better images than the sector probe. Of the various scanning perspectives, the paramedian longitudinal approach offered the best views at both cord levels. Broken down by age groups, the best visibility was clearly obtained in neonates up to 3 months of age (P < 0.0001 Vs all other age groups). In older children, the quality of ultrasound decreased in an age-dependent manner.

CONCLUSIONS

Paramedian longitudinal scans with linear probes are the most favorable method of imaging neuraxial anatomy at lumbar and thoracic cord levels in infants and children, with the best results in neonates up to 3 months of age. Based on these results, and using real time imaging, a practical technique for ultrasound-guided epidural anesthesia for neonates and infants at lumbar and thoracic levels of the spinal cord is planned.

Regional anaesthesia for orthopaedic surgery

Recently, there has been considerable interest in regional anaesthetic techniques, particularly in peripheral nerve blockade, for orthopaedic limb surgery. Many traditional nerve-block techniques have been significantly modified to improve their role in both in-patient and out-patient surgery. The introduction of long-acting local anaesthetic with a better safety profile as well as better equipment for continuous nerve blockade has further increased the use of such techniques in the provision of postoperative analgesia. The recent developments described in this review are likely to result in wider use of these techniques in years to come.