Development of a mobile ultrasound-guided peripheral nerve block and catheter service

Novel Regional Nerve Blocks in Clinical Practice: Evolving Techniques for Pain Management

This review examines the use of novel US-guided nerve blocks in clinical practice. Erector spinae block is a regional anesthesia technique doing by injecting a local anesthetic among the erector spinae muscle group and transverse processes. The phrenic nerve is a branch of the cervical plexus, arising from the anterior rami of cervical nerves C3, C4, and C5. The quadratus lumborum muscle is located along the posterior abdominal wall. It originates from the transverse process of the L5 vertebral body, the iliolumbar ligament, and the iliac crest. US-guided peripheral nerve procedures have a considerable scope of use, including treating headaches and hiccups to abdominal surgical pain, cesarean sections, musculoskeletal pathologies. These nerve blocks have been an effective addition to clinical anesthesia practice. The use of peripheral nerve blocks has improved postoperative pain, lessened the use of opioids and their potential side effects, and decreased the incidence of sleep disturbance in patients. More research should be done to further delineate the potential benefits of these blocks.

The Use of Magnesium Sulfate and Peripheral Nerve Blocks: An Updated Meta-analysis and Systematic Review

OBJECTIVES

With the popularization of ultrasound, nerve blocks have been widely implemented in current clinical practice. Although, they have seen limited success due to their shorter duration and suboptimal analgesia. Magnesium sulfate as a local anesthetic adjuvant for peripheral nerve blocks could enhance the effects of local anesthetics. However, previous investigations have not thoroughly investigated the analgesic efficacy of magnesium sulfate as an adjunct to local anesthetics for peripheral nerve blocks. Thus, we attempted to fill the gap in the existing literature by conducting a meta-analysis.

MATERIALS AND METHODS

We performed of a quantitative systematic review of randomized controlled trials published between May 30, 2011 and November 1, 2018. Inclusion criteria were: (1) magnesium sulfate used as adjuvant mixed with local anesthetic for nerve blockade, (2) complete articles and published abstracts of randomized controlled trials, (3) English language.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures were time of onset, total duration of the sensory blockade, and Visual Analog Scale pain scores. The secondary outcomes were postoperative oral and intravenous analgesics consumption and the incidence of nausea and vomiting.

RESULTS

The 21 trials analyzed in this study included 1323 patients. Magnesium sulfate effectively prolonged the total duration of sensory blockade (mean difference [MD]=114.59 min, 95% confidence interval [CI]: 89.31-139.88), reducing Visual Analog Scale pain scores at 6 hours (MD=1.36 points, 95% CI: -2.09 to -0.63) and 12 hours (MD=1.54 points, 95% CI: -2.56 to -0.53) postsurgery. Magnesium sulfate also effectively reduced postoperative analgesic use within 24 hours postsurgery (standard MD=-2.06, 95% CI: -2.67 to -1.35). Furthermore, adjuvant magnesium sulfate significantly reduced the incidence of nausea and vomiting after transversus abdominis plane blockade (odds ratio: 0.39, 95% CI: 0.18-0.81).

CONCLUSION

Adjuvant magnesium sulfate enhanced the anesthetic effects of local anesthetics and improved postoperative analgesia following the perineural blockade.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial

OBJECTIVES

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

DESIGN

Multisite randomized controlled trial from April 2009 to March 2013.

SETTING

Three New York hospitals.

PARTICIPANTS

Individuals with hip fracture (N = 161).

INTERVENTION

Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).

MEASUREMENTS

Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.

RESULTS

Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.

CONCLUSION

Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Ultrasound for the anesthesiologists: present and future

Ultrasound is a safe, portable, relatively inexpensive, and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine. Anesthesiologists encounter a variety of emergent situations and may benefit from the application of such a rapid and accurate diagnostic tool in their routine practice. This paper reviews current and potential applications of ultrasound in anesthesiology in order to encourage anesthesiologists to learn and use this useful tool as an adjunct to physical examination. Ultrasound-guided peripheral nerve blockade and vascular access represent the most popular ultrasound applications in anesthesiology. Ultrasound has recently started to substitute for CT scans and fluoroscopy in many pain treatment procedures. Although the application of airway ultrasound is still limited, it has a promising future. Lung ultrasound is a well-established field in point-of-care medicine, and it could have a great impact if utilized in our ORs, as it may help in rapid and accurate diagnosis in many emergent situations. Optic nerve sheath diameter (ONSD) measurement and transcranial color coded duplex (TCCD) are relatively new neuroimaging modalities, which assess intracranial pressure and cerebral blood flow. Gastric ultrasound can be used for assessment of gastric content and diagnosis of full stomach. Focused transthoracic (TTE) and transesophageal (TEE) echocardiography facilitate the assessment of left and right ventricular function, cardiac valve abnormalities, and volume status as well as guiding cardiac resuscitation. Thus, there are multiple potential areas where ultrasound can play a significant role in guiding otherwise blind and invasive interventions, diagnosing critical conditions, and assessing for possible anatomic variations that may lead to plan modification. We suggest that ultrasound training should be part of any anesthesiology training program curriculum.

Regional anesthesia outside the operating room: indications and techniques

PURPOSE OF REVIEW

Regional anesthesia is not only performed in the operating room. There are indications for the use of these techniques for pain relief in the emergency department and for anesthesia support of procedures outside the operating room. In this review, we will provide an overview of the indications for the regional techniques performed in the out-of-operating room environment.

RECENT FINDINGS

In the emergency department, patients may experience significant pain, and adequate analgesia is not always provided. Regional analgesia is effective and indicated for many trauma situations including hip fracture, reduction of shoulder dislocation, treatment of upper limb fractures and multiple rib fractures.Ultrasound guidance makes the performance of regional blocks more accessible and safer for use in the emergency department setting.For therapeutic procedures outside the operating room, regional anesthesia is possible for uterine artery embolization and for postoperative analgesia after implantation of cervical brachytherapy needles.

SUMMARY

Regional anesthesia is a valuable option for analgesia in trauma patients, enabling improved pain control in the emergency department and has benefits in the anesthetic management of therapeutic procedures outside the operating room. For many blocks, ultrasound guidance is useful.