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Mekawy NM, Badawy SS, Sakr SA. Role of postoperative continuous subfascial bupivacaine infusion after posterior cervical laminectomy: Randomized control study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Abstract
PURPOSE OF REVIEW This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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Shanthanna H, Mendis N, Goel A. Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations. Br J Anaesth 2016; 116:192-207. [PMID: 26787789 DOI: 10.1093/bja/aev453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use. We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries. The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.
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Affiliation(s)
- H Shanthanna
- Department of Anaesthesiology, St Joseph's Hospital, McMaster University, Hamilton, ON, Canada
| | - N Mendis
- Resident, Department of Anaesthesiology, University of Ottawa, Ottawa, ON, Canada
| | - A Goel
- Resident, Department of Anesthesiology, University of Toronto, Toronto, ON, Canada
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Kim JY, Song KS, Kim WJ, Park YH, Kang H, Woo YC, Shin HY. Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2016; 24:931-9. [PMID: 26063452 DOI: 10.1007/s00167-015-3667-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/29/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE Randomized controlled trials, Therapeutic study, Level I.
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Affiliation(s)
- Jae-Yoon Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Won-Joong Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Young-Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hwa-Yong Shin
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea.
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Park SK, Choi YS, Choi SW, Song SW. A comparison of three methods for postoperative pain control in patients undergoing arthroscopic shoulder surgery. Korean J Pain 2015; 28:45-51. [PMID: 25589946 PMCID: PMC4293507 DOI: 10.3344/kjp.2015.28.1.45] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 11/18/2022] Open
Abstract
Background Arthroscopic shoulder operations (ASS) are often associated with severe postoperative pain. Nerve blocks have been studied for pain in shoulder surgeries. Interscalene brachial plexus blocks (ISB) and an intra-articular injection (IA) have been reported in many studies. The aim of the present study is to evaluate the effect of ISB, a continuous cervical epidural block (CCE) and IA as a means of postoperative pain control and to study the influence of these procedures on postoperative analgesic consumption and after ASS. Methods Fifty seven patients who underwent ASS under general anesthesia were randomly assigned to one of three groups: the ISB group (n = 19), the CCE group (n = 19), and the IA group (n = 19). Patients in each group were evaluated on a postoperative numerical rating scale (NRS), their rescue opioid dosage (ROD), and side effects. Results Postoperative NRSs were found to be higher in the IA group than in the ISB and CCE groups both at rest and on movement. The ROD were 1.6 ± 2.3, 3.0 ± 4.9 and 7.1 ± 7.9 mg morphine equivalent dose in groups CCE, ISB, and IA groups (P = 0.001), respectively, and statistically significant differences were noted between the CCE and IA groups (P = 0.01) but not in between the ISB and CCE groups. Conclusions This prospective, randomized study demonstrated that ISB is as effective analgesic technique as a CCE for postoperative pain control in patients undergoing ASS.
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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Sung Wook Choi
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju, Korea
| | - Sung Wook Song
- Department of Emergency Medicine, Jeju National University Hospital, Jeju, Korea
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Carvalho JCA, Khemka R, Loke J, Tsui BCH. Low-dose intrathecal local anesthetic does not increase the threshold current for the epidural stimulation test: a prospective observational trial of neuraxial analgesia in labouring women. Can J Anaesth 2014; 62:265-70. [PMID: 25501494 DOI: 10.1007/s12630-014-0291-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the ability of the electrical epidural stimulation test (EST) to determine the position of the epidural catheter during combined spinal-epidural (CSE) anesthesia for labour analgesia. METHODS This was a prospective observational trial of attempted EST during neuraxial analgesia in labouring women. Ten women received a double-segment CSE technique and one woman underwent continuous spinal analgesia following inadvertent dural puncture and deliberate placement of the catheter tip in the intrathecal space. In all CSE cases, the spinal injection was performed below the level of the epidural insertion. The motor threshold current (MTC) was determined by EST through the existing epidural/intrathecal catheter immediately following and at five, ten, and 15 mins after intrathecal injection of bupivacaine 1.75 mg and fentanyl 15 μg. Changes in the MTC were expressed as a percent change compared with baseline. RESULTS The MTC required to elicit muscle contractions in women with epidurally placed catheters was unaffected by the intrathecal injection of the analgesic mixture (P = 0.731). The MTC increased following an intrathecal injection of the same mixture in a woman who had the catheter placed intrathecally. CONCLUSIONS The intrathecal injection of a low dose of bupivacaine-fentanyl does not affect the MTC if the catheter is placed in the epidural space; however, it does affect the threshold if the catheter is placed intrathecally. We also confirm that the EST can help to determine the position of the epidural catheter prior to injection of the test dose. This trial was registered at ClinicalTrials.gov (NCT00464841).
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Affiliation(s)
- Jose C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Abdallah FW, Chan VWS. From the journal archives: Practical applicability of the epidural electrical stimulation test. Can J Anaesth 2014; 61:881-5. [PMID: 24682856 DOI: 10.1007/s12630-014-0145-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 03/10/2014] [Indexed: 12/01/2022] Open
Affiliation(s)
- Faraj W Abdallah
- Department of Anesthesia and Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Keys to minimizing the risk of spinal cord trauma during a lumbar approach to thoracic epidural. Can J Anaesth 2014; 61:289-94. [PMID: 24477465 DOI: 10.1007/s12630-014-0120-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022] Open
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Tsui BCH. The electrophysiological principles of the electrical stimulation test in the epidural compartment. Can J Anaesth 2013; 60:1270-1. [PMID: 24105620 DOI: 10.1007/s12630-013-0033-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022] Open
Affiliation(s)
- Ban C H Tsui
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada,
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Electrophysiological stimulation (Tsui test) is feasible for epidural catheter positioning in adults with chronic back pain: a cohort study. Can J Anaesth 2013; 60:976-81. [DOI: 10.1007/s12630-013-0002-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022] Open
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Lee JH, Yoon DM, Kwon TD, Yoon KB. An evaluation of contrast medium spread on caudal epidurography with the needle positioned toward the affected side in patients with unilateral lumbosacral radiculopathy. Skeletal Radiol 2012; 41:1613-8. [PMID: 22270453 DOI: 10.1007/s00256-011-1354-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 12/16/2011] [Accepted: 12/19/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We used caudal epidurography to compare the spread of contrast medium when the needle was inserted toward the affected side in patients with unilateral radiculopathy undergoing caudal steroid injection. MATERIALS AND METHODS We enrolled 24 patients with unilateral radiculopathy. A block needle was positioned toward the affected side in the sacral epidural space. After 5 mL of iodinated contrast medium was injected, a standardized anteroposterior view was imaged. Using Adobe Photoshop software, contrast medium spread was assessed by counting pixels within the areas spread on the affected side and on the opposite side, and the pixel counts of the two sides were compared. Spinal nerve root filling was also assessed. RESULTS The pixel count within the area of contrast medium spread on the side with the needle was significantly greater than that of the opposite side (mean [SD] 41,368.6 [13,143.1] vs 15,165.3 (10,698.1), P < 0.001]. However, 13.6% of the study patients had greater spread on the opposite side. The rates of L5 and S1 nerve root filling in the affected side were 18.2% and 36.4% respectively. CONCLUSIONS When a needle was intentionally inserted toward the side with radiculopathy, the spread of contrast medium and number of delineated roots tended to be greater on the side with the needle, compared with those on the opposite side. However, the pattern of contrast medium spread in the sacral epidural space varied and some patients even had greater spread on the opposite side.
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Affiliation(s)
- Jae Hoon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, South Korea
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Elder JB, Hoh DJ, Liu CY, Wang MY. Postoperative continuous paravertebral anesthetic infusion for pain control in posterior cervical spine surgery: a case-control study. Neurosurgery 2010; 66:99-106; discussion 106-7. [PMID: 20173578 DOI: 10.1227/01.neu.0000349208.87863.b3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Patients who undergo posterior cervical spinal fusion procedures frequently experience significant postoperative pain. Use of a local anesthetic continuous infusion pump after surgery may improve these outcome variables. METHODS After posterior cervical spine fusion procedures, 25 consecutive patients received continuous infusion of 0.5% bupivacaine into the subfascial aspects of the wound via an elastomeric pump. Data were collected prospectively by third party assessment using standard nursing protocols. This included numeric pain scores and opiate use over the first 4 postoperative days (PODs), length of hospitalization, and complications. In a retrospective analysis, we compared each study patient to a control patient who did not receive the continuous infusion of bupivacaine. Demographic variables and surgical procedure were similar among matched cases. RESULTS Patients receiving continuous local anesthetic infusion used significantly less narcotics (P < .05) during the first 4 PODs: 24.4% on day 1, 34.1% on day 2, 53.5% on day 3, and 58.1% on day 4. A lower average pain score was observed among study patients on each POD (P < .05): 31.5% less on day 1, 13.0% on day 2, 24.0% on day 3, and 35.7% on day 4. Patients with the infusion device were discharged home earlier (POD 4.9 versus 6.7; P = .024) and demonstrated improvement in time to ambulation, first bowel movement, and discontinuation of the patient-controlled analgesia machine. No complications were associated with the device. CONCLUSION Patients with the local anesthetic continuous infusion device required less narcotics and reported lower pain scores than control patients on each of the first 4 PODs. These results suggest that continuous infusion of local anesthetic into the paravertebral tissue during the immediate postoperative period is a safe and effective technique that achieves lower pain scores and narcotic use and improves multiple postoperative outcome variables.
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Affiliation(s)
- James B Elder
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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Garcia-Pereira FL, Hauptman J, Shih AC, Laird SE, Pease A. Evaluation of electric neurostimulation to confirm correct placement of lumbosacral epidural injections in dogs. Am J Vet Res 2010; 71:157-60. [DOI: 10.2460/ajvr.71.2.157] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tsui BCH, Bury J, Bouliane M, Ganapathy S. Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery. Acta Anaesthesiol Scand 2007; 51:255-60. [PMID: 17096670 DOI: 10.1111/j.1399-6576.2006.1184.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous cervical epidural anesthesia can provide excellent peri- and post-operative analgesia, although several factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low-current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. METHODS After Institutional Review Board approval, adult patients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1-10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch responses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2-8 ml/h) of ropivacaine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. RESULTS Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8 +/- 2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4-7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. CONCLUSION This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.
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Affiliation(s)
- B C H Tsui
- Departments of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Edmonton, Alberta, Canada.
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