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Axonal Injury with Persistent Neuropathy following Popliteal Nerve Block for Cheilectomy Surgery. Case Rep Anesthesiol 2021; 2021:9942195. [PMID: 34285818 PMCID: PMC8275396 DOI: 10.1155/2021/9942195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Peripheral nerve blocks are often used for foot and ankle surgery. The occurrence of persistent neurological symptoms thereafter is very rare. Preventive strategies pose no guarantee and uncovering true etiology is often complicated. We discuss a case in which a young, healthy patient developed nerve damage after an uneventful popliteal block and cheilectomy. Nerve conduction studies revealed axonal injury in the distribution area of the sciatic nerve. The neurological symptoms persisted for more than 12 months, emotionally affecting the patient greatly. Patients will primarily report to the orthopedic surgeon, for whom cooperation with anaesthesia and neurology is of importance. Anesthetic involvement probably improves patient satisfaction during complication management.
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Ferri CA, Quevedo AAF. Nerve stimulator for regional anaesthesia procedures with automatic interactive closed-loop control. J Med Eng Technol 2019; 42:553-561. [PMID: 30875265 DOI: 10.1080/03091902.2019.1580321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Peripheral nerve stimulators have widespread among anaesthesiologists and remain a popular technique. However, in commercial devices, the user has to manually adjust stimulus intensity. Thus, the aim of this study is to propose a method that allows automating the current intensity control. An earlier nerve stimulator prototype was modified to add an accelerometer and an sEMG module. The choice of these two sensors is aimed at the possibility of observing the mechanical and electrical responses of the muscle contraction evoked by the stimulation. The tests were performed in two steps. The first step was to observe how the sensors behave during stimulation and muscle contraction. The second step was to implement a control algorithm and to validate the automation technique. Comparing the two methods, no significant differences were found on procedure time (manual: 12.5 ± 2.3; automatic: 11.6 ± 1.9; ρ =0.380) and blockade latency time (manual: 11.6 ± 1.1; automatic: 11.9 ± 1.2; ρ =0.524). Comparing needle-nerve distance in manual or automatic mode, no significant differences were found for 1.0 mA, 0.8 mA, 0.5 mA and 0.3 mA. We conclude that the technique for automating the current intensity update, using accelerometer and/or electromyography, is satisfactory. Furthermore, we conclude that the use of the accelerometer alone is sufficient for detection of muscle contraction.
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Affiliation(s)
- Carlos A Ferri
- a Department of Biomedical Engineering, School of Electrical and Computer Engineering , University of Campinas , Campinas , Brazil
| | - Antonio A F Quevedo
- a Department of Biomedical Engineering, School of Electrical and Computer Engineering , University of Campinas , Campinas , Brazil.,b Center of Biomedical Engineering , University of Campinas , Campinas , Brazil
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Gili S, Abreo A, GóMez-Fernández M, Solà R, Morros C, Sala-Blanch X. Patterns of Distribution of the Nerves Around the Axillary Artery Evaluated by Ultrasound and Assessed by Nerve Stimulation During Axillary Block. Clin Anat 2019; 32:2-8. [DOI: 10.1002/ca.23225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/15/2018] [Accepted: 06/05/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Sara Gili
- Master Advanced Medical Competences in Regional Anesthesia Based on Anatomy, Faculty of Medicine; University of Barcelona; Barcelona Spain
| | - Angelica Abreo
- Department of Anesthesiology; MC Mutual; Barcelona Spain
| | | | - Roma Solà
- Department of Neurology; MC Mutual, Barcelona, Neuroscience Technologies SLP, Parc Científic; Barcelona Spain
| | - Carlos Morros
- Department of Anesthesiology; Clínica Diagonal; Barcelona Spain
| | - Xavier Sala-Blanch
- Department of Anesthesiology; Hospital Clínic, Universitat de Barcelona; Barcelona Spain
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Wiesmann T, Müller S, Müller HH, Wulf H, Steinfeldt T. Effect of bupivacaine and adjuvant drugs for regional anesthesia on nerve tissue oximetry and nerve blood flow. J Pain Res 2018; 11:227-235. [PMID: 29416372 PMCID: PMC5789040 DOI: 10.2147/jpr.s152230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Nerve blood flow has a critical role in acute and chronic pathologies in peripheral nerves. Influences of local anesthetics and adjuvants on tissue perfusion and oxygenation are deemed as relevant factors for nerve damage after peripheral regional anesthesia. The link between low tissue perfusion due to local anesthetics and resulting tissue oxygenation is unclear. Methods Combined tissue spectrophotometry and laser-Doppler flowmetry were used to assess nerve blood flow in 40 surgically exposed median nerves in pigs, as well as nerve tissue oximetry for 60 min. After baseline measurements, test solutions saline (S), bupivacaine (Bupi), bupivacaine with epinephrine (BupiEpi), and bupivacaine with clonidine (BupiCloni) were applied topically. Results Bupivacaine resulted in significant decrease in nerve blood flow, as well as tissue oximetry values, compared with saline control. Addition of epinephrine resulted in a rapid, but nonsignificant, reduction of nerve blood flow and extensive lowering of tissue oximetry levels. The use of clonidine resulted in a reduction of nerve blood flow, comparable to bupivacaine alone (relative blood flow at T60 min compared with baseline, S: 0.86 (0.67-1.18), median (25th-75th percentile); Bupi: 0.33 (0.25-0.60); BupiCloni: 0.43 (0.38-0.63); and BupiEpi: 0.41(0.30-0.54). The use of adjuvants did not result in any relevant impairment of tissue oximetry values (saturation values in percent at T60, S: 91.5 [84-95]; Bupi: 76 [61-86]; BupiCloni: 84.5 [76-91]; and BupiEpi: 91 [56-92]). Conclusion The application of bupivacaine results in lower nerve blood flow, but does not induce relevant ischemia. Despite significant reductions in nerve blood flow, the addition of clonidine or epinephrine to bupivacaine had no significant impact on nerve tissue oximetry compared with bupivacaine alone. Nerve ischemia due to local anesthetics is not enhanced by the adjuvants clonidine or epinephrine.
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Affiliation(s)
- Thomas Wiesmann
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Marburg, Philipps University, Marburg
| | - Stefan Müller
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Marburg, Philipps University, Marburg.,Department of Anesthesiology and Intensive Care Medicine, University Hospital Giessen, Justus-Liebig-University, Giessen
| | - Hans-Helge Müller
- Institute of Medical Biometry and Epidemiology, Philipps University, Marburg
| | - Hinnerk Wulf
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Marburg, Philipps University, Marburg
| | - Thorsten Steinfeldt
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Marburg, Philipps University, Marburg.,Department of Anesthesiology and Intensive Care Medicine, Diakoniekrankenhaus Schwäbisch Hall, Schwäbisch Hall, Germany
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The concept of protective nerve stimulation for ultrasound guided nerve blocks. Med Hypotheses 2017; 107:72-73. [DOI: 10.1016/j.mehy.2017.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/14/2017] [Indexed: 11/18/2022]
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Sondekoppam RV, Tsui BCH. Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks. Anesth Analg 2017; 124:645-660. [DOI: 10.1213/ane.0000000000001804] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Munirama S, Zealley K, Schwab A, Columb M, Corner G, Eisma R, McLeod G. Trainee anaesthetist diagnosis of intraneural injection—a study comparing B-mode ultrasound with the fusion of B-mode and elastography in the soft embalmed Thiel cadaver model. Br J Anaesth 2016; 117:792-800. [DOI: 10.1093/bja/aew337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 11/13/2022] Open
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Vassiliou T, Müller HH, Limberg S, De Andres J, Steinfeldt T, Wiesmann T. Risk evaluation for needle-nerve contact related to electrical nerve stimulation in a porcine model. Acta Anaesthesiol Scand 2016; 60:400-6. [PMID: 26666693 DOI: 10.1111/aas.12664] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/06/2015] [Accepted: 10/19/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND For performing peripheral nerve blocks, the risk for needle-nerve contact (NNC) as an adverse event for low and high current thresholds has not yet been clearly defined when nerve stimulator guided techniques were applied. This experimental study aimed to investigate the risk of NNCs when applying stimulation currents between 0.1 and 2 mA (in increments of 0.1 mA). METHODS Brachial plexus nerves were exposed surgically in five anesthetized pigs. An insulated needle connected to a nerve stimulator was placed at 10 mm distance to the targeted nerves. Current intensity was adjusted according to randomization (0.1-2.0 mA, increments of 0.1 mA). The needle tip was advanced toward the nerve until a motor response was elicited. The frequencies of NNCs for each of the adjusted current intensities were noted. Risks of NNCs were calculated according to the analysis of 95% confidence intervals (95% CI). RESULTS We executed 2000 needle placements with stimulation currents ranging from 0.1 to 2.0 mA. The risks for NNC at low current intensities were 0.85 (95% CI, 0.77-0.91) for 0.3 mA and 0.5 (95% CI, 0.4-0.6) for 0.5 mA, respectively. For high current intensities, risks of 0.13 (95% CI, 0.07-0.21) for 0.9 mA and 0.01 (95% CI, 0-0.05) for 1.1 mA were calculated. CONCLUSIONS In this experimental animal study, a relevant reduction in the risk of NNCs could be observed when high current intensities (0.9-1.1 mA) were applied compared to low current intensities (0.3-0.5 mA).
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Affiliation(s)
- T Vassiliou
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - H-H Müller
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany
| | - S Limberg
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - J De Andres
- Department of Anaesthesiology and Critical Care, University General Hospital Valencia, Valencia, Spain
| | - T Steinfeldt
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
| | - T Wiesmann
- Department of Anaesthesiology and Critical Care, University Hospital Gießen-Marburg, Philipps-University Marburg, Marburg, Germany
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Sauter AR, Romundstad L. Animal models can help us prevent nerve injuries in regional anaesthesia for patients. Acta Anaesthesiol Scand 2016; 60:284-8. [PMID: 26806955 DOI: 10.1111/aas.12680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A. R. Sauter
- Department of Research and Developement; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
- Department of Anesthesiology and Pain Medicine; lnselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - L. Romundstad
- Division of Emergencies and Critical Care; Department of Anaesthesiology; Oslo University Hospital; Rikshospitalet; Oslo Norway
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Krol A, De Andres J. Plexus and peripheral nerve block anaesthesia--a step beyond ultrasound or full circle? ACTA ACUST UNITED AC 2016; 63:129-34. [PMID: 26782289 DOI: 10.1016/j.redar.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022]
Affiliation(s)
- A Krol
- Department of Anaesthesia and Chronic Pain Service, St Georges University Hospitals, London, UK.
| | - J De Andres
- Department of Anaesthesia, Critical Care and Pain Management, University of Valencia, School of Medicine, General University Hospital, Valencia, Spain
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A comparison of motor stimulation threshold in ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery: a randomized trial. Can J Anaesth 2015; 63:461-7. [DOI: 10.1007/s12630-015-0553-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 10/10/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022] Open
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Brull R, Hadzic A, Reina MA, Barrington MJ. Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade. Reg Anesth Pain Med 2015; 40:479-90. [PMID: 25974275 DOI: 10.1097/aap.0000000000000125] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review synthesizes anatomical, anesthetic, surgical, and patient factors that may contribute to neurologic complications associated with peripheral nerve blockade. Peripheral nerves have anatomical features unique to a given location that may influence risk of injury. Peripheral nerve blockade-related peripheral nerve injury (PNI) is most severe with intrafascicular injection. Surgery and its associated requirements such as positioning and tourniquet have specific risks. Patients with preexisting neuropathy may be at an increased risk of postoperative neurologic dysfunction. Distinguishing potential causes of PNI require clinical assessment and investigation; a definitive diagnosis, however, is not always possible. Fortunately, most postoperative neurologic dysfunction appears to resolve with time, and the incidence of serious long-term nerve injury directly attributable to peripheral nerve blockade is relatively uncommon. Nonetheless, despite the use of ultrasound guidance, the risk of block-related PNI remains unchanged. WHAT'S NEW Since the 2008 Practice Advisory, new information has been published, furthering our understanding of the microanatomy of peripheral nerves, mechanisms of peripheral nerve injection injury, toxicity of local anesthetics, the etiology of and monitoring methods, and technologies that may decrease the risk of nerve block-related peripheral nerve injury.
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Affiliation(s)
- Richard Brull
- From the *Departments of Anesthesia, Toronto Western Hospital, University Health Network, and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, St Luke's and Roosevelt Hospitals, New York, NY; ‡School of Medicine, CEU San Pablo University, and Madrid Montepríncipe University Hospital, Madrid, Spain; and §Department of Anaesthesia, St Vincent's Hospital; Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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Kalvøy H, Sauter AR. Detection of intraneural needle-placement with multiple frequency bioimpedance monitoring: a novel method. J Clin Monit Comput 2015; 30:185-92. [PMID: 25902898 PMCID: PMC4792358 DOI: 10.1007/s10877-015-9698-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 04/17/2015] [Indexed: 11/01/2022]
Abstract
Electrical impedance measurements have been used to detect intraneural needle placement, but there is still a lack of precision with this method. The purpose of the study was to develop a method for the discrimination of nerve tissue from other tissue types based on multiple frequency impedance measurements. Impedance measurements with 25 different frequencies between 1.26 and 398 kHz were obtained in eight pigs while placing the tip of a stimulation needle within the sciatic nerve and in other tissues. Various impedance variables and measurement frequencies were tested for tissue discrimination. Best tissue discrimination was obtained by using three different impedance parameters with optimal measurement frequencies: Modulus (126 kHz), Phase angle (40 kHz) and the Delta of the phase angle (between 126 and 158 kHz). These variables were combined in a Compound variable C. The area under the curve in a receiver operating characteristic was consecutively increased for the Modulus (78 %), Phase angle (86 %), Delta of the phase angle (94 %), and the Compound variable C (97 %), indicating highest specificity and sensitivity for C. An algorithm based on C was implemented in a real-time feasibility test and used in an additional test animal to demonstrate our new method. Discrimination between nerve tissue and other tissue types was improved by combining several impedance variables at multiple measurement frequencies.
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Affiliation(s)
- Håvard Kalvøy
- Department of Clinical and Biomedical Engineering, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Axel R Sauter
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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When the statistics steal the show. Anesthesiology 2015; 122:952-3. [PMID: 25782645 DOI: 10.1097/aln.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Steinfeldt T, Wiesmann T. Needle-nerve proximity during peripheral nerve blocks--where is the right target and how can we get there? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:121-124. [PMID: 25677677 DOI: 10.1016/j.redar.2015.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 01/19/2015] [Indexed: 06/04/2023]
Affiliation(s)
- T Steinfeldt
- Anaesthesiologist, Consultant; Dep. of Anaesthesia and Intensive Care Therapy, Philipps University Hospital, Philipps-University, Baldingerstr., 35033 Marburg, Germany.
| | - T Wiesmann
- Anaesthesiologist, Staff; Dep. of Anaesthesia and Intensive Care Therapy, Philipps University Hospital, Philipps-University, Baldingerstr., 35033 Marburg, Germany
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The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2015; 40:401-30. [DOI: 10.1097/aap.0000000000000286] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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