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Baker E, Battle C, Lee G. Blunt mechanism chest wall injury: initial patient assessment and acute care priorities. Emerg Nurse 2024; 32:34-42. [PMID: 38468549 DOI: 10.7748/en.2024.e2181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/13/2024]
Abstract
Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.
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Affiliation(s)
- Edward Baker
- King's College Hospital NHS Foundation Trust, London, England
| | - Ceri Battle
- Swansea Bay University Health Board, Swansea, Wales
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England
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Stopenski S, Binkley J, Schubl SD, Bauman ZM. Rib Fracture Management: A Review of Surgical Stabilization, Regional Analgesia, and Intercostal Nerve Cryoablation. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Santonastaso DP, de Chiara A, Russo E, Gamberini E, Musetti G, Cittadini A, Ranieri S, Coccolini F, Fugazzola P, Ansaloni L, Agnoletti V. Alternative Regional Anesthesia for Surgical Management of Multilevel Unilateral Rib Fractures. J Cardiothorac Vasc Anesth 2020; 34:1281-1284. [DOI: 10.1053/j.jvca.2019.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 12/31/2022]
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Improved Analgesic Effect of Paravertebral Blocks before and after Video-Assisted Thoracic Surgery: A Prospective, Double-Blinded, Randomized Controlled Trial. Pain Res Manag 2019; 2019:9158653. [PMID: 31827657 PMCID: PMC6885800 DOI: 10.1155/2019/9158653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022]
Abstract
Despite being less invasive, patients who underwent video-assisted thoracic surgery (VATS) suffered considerable postoperative pain. Paravertebral block (PVB) was proven to provide effective analgesia in patients with VATS; however, there is no difference in pain relief between preoperative PVB and postoperative PVB. This study was aimed to investigate the analgesic efficacy of combination of preoperative and postoperative PVB on the same patient undergoing VATS. In this prospective, double-blinded, randomized controlled trial, 44 patients undergoing VATS were enrolled, and they received patient-controlled intravenous analgesia (PCIA) with sufentanil plus preoperative PVB (Group A, n = 15) or postoperative PVB (Group B, n = 15), or combination of preoperative and postoperative PVB (Group C, n = 14). The primary outcome was sufentanil consumption and PCIA press times in the first 24 hours postoperatively. Also, data of postoperative use of PCIA and visual analogue scale (VAS) were collected. In the first 24 hours postoperatively, median sufentanil consumption in Group C was 0 (0–34.75) μg, which was much less than that in Group A (45.00 (33.00–47.00) μg, p=0.005) and Group B (36 (20.00–50.00) μg, p=0.023). Patients in Group C pressed less times of PCIA (0 (0–0) times) than patients in Group A (2 (1–6) times, p < 0.001) and Group B (2 (1–3) times, p=0.009). Kaplan–Meier analysis showed patients with combination of preoperative and postoperative PVB had a higher PCIA-free rate than patients with either technique alone (p=0.003). The VAS among the three groups was comparable postoperatively. The combination of both preoperative and postoperative PVB provides better analgesic efficacy during the early postoperative period and may be an alternative option for pain control after VATS. This trial is registered with ChiCTR1800017102.
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Regional analgesia for patients with traumatic rib fractures: A narrative review. J Trauma Acute Care Surg 2019; 88:e22-e30. [DOI: 10.1097/ta.0000000000002524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hassan ME, Mahran E. Effect of adding magnesium sulphate to bupivacaine on the clinical profile of ultrasound-guided thoracic paravertebral block in patients undergoing modified radical mastectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2014.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | - Essam Mahran
- Department of Anaesthesia, ICU , National Cancer Institute , Cairo University , Egypt
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Abstract
Regional anesthesia for the acute trauma patient is increasing due to the growing appreciation of its benefits, development of newer techniques and equipment, and more robust training. Block procedures are expanding beyond perioperative interventions performed exclusively by anesthesiologists to paramedics on scene, emergency medicine physicians, and nurse-led services using these techniques early in trauma pain management. Special considerations and indications apply to trauma victims compared with the elective patient and must be appreciated to optimize safety and clinical outcomes. This review discusses current literature and future directions in the growing role of regional anesthesia in acute trauma care.
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Affiliation(s)
- Ian R Slade
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Box 359724, Seattle, WA 98104, USA.
| | - Ron E Samet
- Department of Anesthesiology, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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Hamilton C, Barnett L, Trop A, Leininger B, Olson A, Brooks A, Clark D, Schroeppel T. Emergency department management of patients with rib fracture based on a clinical practice guideline. Trauma Surg Acute Care Open 2017; 2:e000133. [PMID: 29766120 PMCID: PMC5887826 DOI: 10.1136/tsaco-2017-000133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 12/04/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) have the ability to increase efficiency and standardize care. A CPG based on forced vital capacity (FVC) for rib fractures was developed as a tool for triage of these patients. The objectives of this study were to assess the efficacy and compliance of physicians with this rib fracture CPG. Methods Patients >18 that were discharged from an urban level 2 trauma center emergency department (ED) between the dates of January 1, 2014, to December 31, 2016, were eligible for the study. Demographics, mechanism, outcomes and FVC were abstracted by review of the electronic medical record. Compliance with the CPG was examined, and comparisons were made between patients successfully discharged and patients who returned. Results 455 patients met were identified during the study period. 233 were eligible after exclusions. 64% of the cohort was male with median age of 53 years. Falls were the most common mechanism (59.6%). The median number of rib fractures was 2 and median FVC 2500 mL. 28 (12.0%) of the 233 returned to the ED after discharge. The groups were well matched with no significant differences. The most common reason for return was pain (95%). Adjusted analysis showed that increasing age (adjusted OR (AOR) 0.968) and FVC (AOR 0.999) were independent predictors. Adherence with the CPG was good for hemothorax/pneumothorax and bilateral fractures (96%), but lagged with the number of fractures (74%). Conclusions This study confirms that the rib fracture CPG is safe and an FVC of 1500 mL is a safe criterion for discharging patients with rib fractures. Interestingly, it appears that older age is protective. More work needs to be done on effective pain control to decrease return to ED visits using this CPG. Level of evidence IV. Type of study Therapeutic.
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Affiliation(s)
| | - Lauren Barnett
- Department of Emergency Medicine, University of Colorado Health-South, Memorial Hospital, Colorado Springs, Colorado, USA
| | - Allison Trop
- Department of Emergency Medicine, University of Colorado Health-South, Memorial Hospital, Colorado Springs, Colorado, USA
| | - Brian Leininger
- Department of Trauma and Acute Care Surgery, University of Colorado Health-South, Memorial Hospital, Colorado Springs, Colorado, USA
| | - Adam Olson
- Rocky Vista University, Parker, Colorado, USA
| | | | | | - Thomas Schroeppel
- Department of Trauma and Acute Care Surgery, University of Colorado Health-South, Memorial Hospital, Colorado Springs, Colorado, USA
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Yeying G, Liyong Y, Yuebo C, Yu Z, Guangao Y, Weihu M, Liujun Z. Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures. J Int Med Res 2017. [PMID: 28635359 PMCID: PMC5805206 DOI: 10.1177/0300060517710068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objectives To assess the effect of thoracic paravertebral block (PVB) on pain management
and preservation of pulmonary function compared with intravenous,
patient-controlled analgesia (IVPCA) in patients with multiple rib fractures
(MRFs). Methods Ninety patients with unilateral MRFs were included in this prospective study
and randomly assigned to the TPVB or IVPCA group. The visual analogue scale
(VAS) pain score, blood gas analysis, and bedside spirometry were measured
and recorded at different time points after analgesia. Results TPVB and IVPCA provided good pain relief. VAS scores were significantly lower
in the TPVB group than in the IVPCA group at rest and during coughing
(P < 0.05). Patients in the TPVB group had a higher
PaO2 and PaO2/FiO2 and lower
P(A–a)O2 compared with the IVPCA group
(P < 0.05). Moreover, patients in the TPVB group
showed higher FVC, FEV1/FVC, and PEFR, and fewer complications than did the
IVPCA group (P < 0.05). Conclusion TPVB is superior to IVPCA in pain relief and preservation of pulmonary
function in patients with MRFs.
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Affiliation(s)
- Ge Yeying
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Yuan Liyong
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Chen Yuebo
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Zhang Yu
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Ye Guangao
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Ma Weihu
- 2 Department of Orthopeadic Surgery, Ningbo 6th Hospital, Ningbo 315040, China
| | - Zhao Liujun
- 2 Department of Orthopeadic Surgery, Ningbo 6th Hospital, Ningbo 315040, China
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De Oliveira GS, Bialek J, Marcus RJ, McCarthy R. Dose-ranging effect of systemic diphenhydramine on postoperative quality of recovery after ambulatory laparoscopic surgery: a randomized, placebo-controlled, double-blinded, clinical trial. J Clin Anesth 2016; 34:46-52. [DOI: 10.1016/j.jclinane.2016.03.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 02/04/2016] [Accepted: 03/14/2016] [Indexed: 11/16/2022]
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Continuous right thoracic paravertebral block following bolus initiation reduced postoperative pain after right-lobe hepatectomy: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2016; 39:506-12. [PMID: 25304475 PMCID: PMC4218764 DOI: 10.1097/aap.0000000000000167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Objectives We hypothesized that continuous right thoracic paravertebral block, following bolus initiation, decreases opioid consumption after right-lobe hepatectomy in patients receiving patient-controlled intravenous analgesia with sufentanil. Methods Patients undergoing right-lobe hepatectomy with a right thoracic paravertebral catheter placed at T7 30 minutes before surgery were randomly assigned to receive through this catheter either a 10-mL bolus of 0.2% ropivacaine before emergence, followed by a continuous infusion of 6 mL/h for 24 hours (PVB group), or saline at the same scheme of administration (control group). All patients were started on patient-controlled intravenous analgesia with sufentanil in the postanesthesia care unit. The primary outcome measure was total sufentanil consumption during the first 24 postoperative hours. P = 0.05 was considered as significant. For the multiple comparisons of data at 5 different time points, the P value for the 0.05 level of significance was adjusted to 0.01. Results Sixty-six patients were assessed for eligibility, and a PVB catheter was successfully placed for 48 patients. Data were analyzed on 22 patients in group PVB and 22 patients in the control group. The cumulative sufentanil consumption in the PVB group (54.3 ± 12.1 μg) at 24 postoperative hours was more than 20% less than that of the control group (68.1 ± 9.9 μg) (P < 0.001). There was also a significant difference in pain scores (numerical rating scale) between groups, where the PVB group had lower scores than did the control group at rest and with coughing for the first 24 hours (P < 0.001). Conclusions Continuous right thoracic paravertebral block, following bolus initiation, has an opioid-sparing effect on sufentanil patient-controlled intravenous analgesia for right-lobe hepatectomy patients and reduces numerical rating scale pain scores at rest and with coughing in the first 24 postoperative hours.
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Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth 2015; 8:45-55. [PMID: 26316813 PMCID: PMC4540140 DOI: 10.2147/lra.s55322] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.
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Affiliation(s)
- Jeff Gadsden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Alicia Warlick
- Department of Anesthesiology, Duke University, Durham, NC, USA
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Cutshall C, Hutchins J. Ultrasound-Guided Continuous Thoracic Paravertebral Catheter Management of Acute Rib Pain Secondary to Cystic Fibrosis Exacerbation in a Pediatric Patient. ACTA ACUST UNITED AC 2015; 4:29-30. [DOI: 10.1213/xaa.0000000000000046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Treatment of postmastectomy pain with ambulatory continuous paravertebral nerve blocks: a randomized, triple-masked, placebo-controlled study. Reg Anesth Pain Med 2014; 39:89-96. [PMID: 24448512 DOI: 10.1097/aap.0000000000000035] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We aimed to determine with this randomized, triple-masked, placebo-controlled study if benefits are afforded by adding a multiple-day, ambulatory, continuous ropivacaine paravertebral nerve block to a single-injection ropivacaine paravertebral block after mastectomy. METHODS Preoperatively, 60 subjects undergoing unilateral (n = 24) or bilateral (n = 36) mastectomy received either unilateral or bilateral paravertebral perineural catheter(s), respectively, inserted between the third and fourth thoracic transverse process(es). All subjects received an initial bolus of ropivacaine 0.5% (15 mL) via the catheter(s). Subjects were randomized to receive either perineural ropivacaine 0.4% or normal saline using portable infusion pump(s) [5 mL/h basal; 300 mL reservoir(s)]. Subjects remained hospitalized for at least 1 night and were subsequently discharged home where the catheter(s) were removed on postoperative day (POD) 3. Subjects were contacted by telephone on PODs 1, 4, 8, and 28. The primary end point was average pain (scale, 0-10) queried on POD 1. RESULTS Average pain queried on POD 1 for subjects receiving perineural ropivacaine (n = 30) was a median (interquartile) of 2 (0-3), compared with 4 (1-5) for subjects receiving saline (n = 30; 95% confidence interval difference in medians, -4.0 to -0.3; P = 0.021]. During this same period, subjects receiving ropivacaine experienced a lower severity of breakthrough pain (5 [3-6] vs 7 [5-8]; P = 0.046) as well. As a result, subjects receiving perineural ropivacaine experienced less pain-induced physical and emotional dysfunction, as measured with the Brief Pain Inventory (lower score = less dysfunction): 14 (4-37) versus 57 (8-67) for subjects receiving perineural saline (P = 0.012). For the subscale that measures the degree of interference of pain on 7 domains, such as general activity and relationships, subjects receiving perineural saline reported a median score 10 times higher (more dysfunction) than those receiving ropivacaine (3 [0-24] vs 33 [0-44]; P = 0.035). In contrast, after infusion discontinuation, there were no statistically significant differences detected between treatment groups. CONCLUSIONS After mastectomy, adding a multiple-day, ambulatory, continuous ropivacaine infusion to a single-injection ropivacaine paravertebral nerve block results in improved analgesia and less functional deficit during the infusion. However, no benefits were identified after infusion discontinuation.
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Visoiu M. Outpatient analgesia via paravertebral peripheral nerve block catheter and On-Q pump--a case series. Paediatr Anaesth 2014; 24:875-8. [PMID: 24815589 DOI: 10.1111/pan.12427] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 11/30/2022]
Abstract
Outpatient pain management after iliac crest bone harvesting can be challenging. We report the use of home L2 paravertebral nerve block catheter (L2PVBC) in a series of five children. The pain scores were low, and analgesic medication consumption was minimal. No complications were reported related with these catheters, and the patients reported very high pain control satisfaction scores. Outpatient L2PVBC can be beneficial as part of a multimodal analgesia strategy in selected pediatric patients.
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Affiliation(s)
- Mihaela Visoiu
- Department of Anesthesiology, Acute Interventional Pediatric Perioperative Pain Service, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Vandepitte C, Latmore M, O’Murchu E, Hadzic A, Van de Velde M, Nijs S. Combined interscalene-superficial cervical plexus blocks for surgical repair of a clavicular fracture in a 15-week pregnant woman. Int J Obstet Anesth 2014; 23:194-5. [DOI: 10.1016/j.ijoa.2013.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/03/2013] [Accepted: 10/07/2013] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW There has been an increasing use of peripheral nerve blocks (PNBs) in ambulatory surgery. Several recent reports have contributed to our understanding of the optimal PNB technique for specific surgical procedures in this setting. In this review, we have summarized the available literature on indications of PNBs for outpatient surgery of the upper extremity. RECENT FINDINGS Although many of the recent studies focus on technical aspects of PNBs, few center on evidence-based indications or their utility in the ambulatory setting. The available literature suggests that although multiple techniques have been reported for outpatient shoulder surgery, interscalene brachial plexus block (ISBPB) is currently the most preferred technique. Supraclavicular, infraclavicular, and axillary brachial plexus blocks, however, are all commonly used and effective PNBs for outpatient surgery and analgesia of the arm, forearm, and hand. SUMMARY ISBPB is currently the most beneficial PNB for outpatient shoulder surgery. Supraclavicular block functionally can be considered an alternative to the traditional ISBPB; however, additional studies are required before routine use can be recommended. Although the review identified several reports with benefits of one PNB technique over the others, the existing literature suggests that many of these techniques may be interchangeable with regards to procedures of the distal upper extremity. Future studies are indicated to help standardize the techniques, selection, and postoperative management of PNBs for specific surgical indications.
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Abstract
PURPOSE OF REVIEW Pain management in the trauma patient can be challenging, especially outside the operating room setting. Traditional analgesics such as opioids and NSAIDs are also problematic in trauma care. In this review, the use of regional anesthetic techniques outside the operating theatre is discussed. RECENT FINDINGS Regional anesthesia is an increasing but still underutilized clinical tool for the trauma patient outside the operating room. Regional anesthesia provides well tolerated and effective analgesia and anesthesia for many indications in the trauma setting including hip fracture, reduction of joint dislocation, wound debridement, laceration repair, and multiple rib fractures. Its use can increase safety and resource allocation in emergency departments. Performance of peripheral nerve blocks, especially with ultrasound, is amenable in various medical environments with minimal training. SUMMARY Pain is often poorly managed in the trauma patient. In addition to quality analgesia, regional anesthesia provides a variety of benefits in the trauma setting outside the traditional operating room setting. While further utilization requires increased training and structural changes, existing tools such as ultrasound are removing barriers to the widespread use of peripheral nerve block techniques across multiple disciplines.
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