1
|
Cho JS, Jotwani R, Chan S, Thaker DM, On JD, Yong RJ, Hao D. Extended reality navigation for pain procedures: a narrative review. Reg Anesth Pain Med 2024:rapm-2024-105352. [PMID: 38754990 DOI: 10.1136/rapm-2024-105352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Extended reality (XR) technology, encompassing virtual reality, augmented reality, and mixed reality, has been widely studied for procedural navigation in surgical specialties. Similar to how ultrasound transformed regional anesthesia, XR has the potential to reshape how anesthesiologists and pain physicians perform procedures to relieve pain. OBJECTIVE This narrative review examines the clinical benefits of XR for navigation in various pain procedures. It defines key terms and concepts related to XR technology and explores characteristics of procedures that are most amenable to XR-based navigation. Finally, it suggests best practices for developing XR navigation systems and discusses the role of emerging technology in the future of XR in regional anesthesia and pain medicine. EVIDENCE REVIEW A search was performed across PubMed, Embase, and Cochrane Central Register of Controlled Trials for primary literature investigating the clinical benefits of XR navigation for pain procedures. FINDINGS Thirteen studies using XR for procedural navigation are included. The evidence includes randomized controlled trials, retrospective studies, and case series. CONCLUSIONS Early randomized controlled trials show potential for XR to improve procedural efficiency, but more comprehensive research is needed to determine if there are significant clinical benefits. Case reports demonstrate XR's utility in generating patient-specific navigation plans when difficult anatomy is encountered. Procedures that facilitate the generation and registration of XR images are most conducive to XR navigation, whereas those that rely on frequent re-imaging will continue to depend on traditional modes of navigation.
Collapse
Affiliation(s)
- James Sungjai Cho
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rohan Jotwani
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | | | - Devaunsh Manish Thaker
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Health, New York, New York, USA
| | - Jungmin Daniel On
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - R Jason Yong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David Hao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Aguilera G, Tabilo C, Jara Á, Aliste J. 0.25% bupivacaine-1% lidocaine vs 0.5% bupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105511. [PMID: 38754989 DOI: 10.1136/rapm-2024-105511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION In an effort to shorten onset time, a common practice is to add lidocaine to bupivacaine. In the setting of infraclavicular block, it is unclear what the block characteristics of this practice are compared with bupivacaine alone. We hypothesized that bupivacaine alone increases the duration of motor block, sensory block, and postoperative analgesia while resulting in a slower onset time compared with a bupivacaine and lidocaine mixture. METHODS 40 patients receiving ultrasound-guided infraclavicular brachial plexus block were randomly assigned to receive either 35 mL of 0.25% bupivacaine and 1% lidocaine or 0.5% bupivacaine, both associated with perineural adjuvants (epinephrine 5 µg/mL and dexamethasone 4 mg). After the block was performed, a blinded observer evaluated the success of the block, the onset time, and the incidence of surgical anesthesia. Postoperatively, a blinded observer contacted patients who had successful blocks to inquire about the duration of motor block, sensory block, postoperative analgesia, and the presence of rebound pain. RESULTS When comparing patients having bupivacaine alone versus bupivacaine and lidocaine, the mean (SD) motor block duration was 28.4 (5.2) vs 18.9 (3.1) hours, respectively; the mean difference 9.5 hours (95% CI 6.5 to 12.4; p<0.001); the mean (SD) sensory block duration was 29.3 (5.8) vs 18.7 (4.0) hours, respectively; the mean difference 10.6 hours (95% CI 7.1 to 14.0; p<0.001); the mean (SD) postoperative analgesia duration was 38.3 (7.4) vs 24.3 (6.6) hours, respectively; the mean difference 14 hours (95% CI 9.2 to 18.8; p<0.001); and the median (IQR) onset time was 35 (15) vs 20 (10) min, respectively; p<0.001. No other significant differences were detected. CONCLUSIONS Compared with mixed bupivacaine-lidocaine, 0.5% bupivacaine significantly prolongs sensorimotor block and postoperative analgesia at the expense of a delayed onset time. TRIAL REGISTRATION NUMBER NCT05834023.
Collapse
Affiliation(s)
| | | | - Álvaro Jara
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Julián Aliste
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| |
Collapse
|
3
|
Hirai N, Tanaka N, Suzuka T, Kadoya Y, Kawaguchi M. Letter to the editor regarding 'Modified thoracoabdominal nerve block through perichondrial approach (M-TAPA): an anatomical study evaluating dye spread following simulated injection in soft embalmed Thiel cadaver'. Reg Anesth Pain Med 2024; 49:376-377. [PMID: 37258033 DOI: 10.1136/rapm-2023-104686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Natsuko Hirai
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Nobuhiro Tanaka
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Takanori Suzuka
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuma Kadoya
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
4
|
Esquerré T, Mure M, Minville V, Prevost A, Lauwers F, Ferré F. Bilateral ultrasound-guided maxillary and mandibular combined nerves block reduces morphine consumption after double-jaw orthognathic surgery: a randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105497. [PMID: 38697776 DOI: 10.1136/rapm-2024-105497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Double-jaw surgeries are known to be painful and to require opioids. Maxillary (V2) and mandibular (V3) nerves block could provide adequate pain management with minimal opioid-related side effects. Our main objective was to evaluate the analgesic effect of bilateral ultrasound-guided V2 and V3 combined nerves block in patients undergoing double-jaw orthognathic surgery. METHODS In this single-blind, randomized control study, 50 patients were prospectively allocated to either bilateral ultrasound-guided V2 and V3 combined nerves block or intraoral infiltration of local anesthetic. Primary outcome was the cumulative oral morphine equivalent (OME) consumption assessed at postoperative day 1. Secondary outcomes were cumulative OME consumption and pain scores in recovery room and at postoperative day 2, intraoperative anesthetic consumption, and opioid-related side effects. Preoperative anxiety was investigated by the Amsterdam Preoperative Anxiety and Information Scale (APAIS). RESULTS Compared with infiltration, ultrasound-guided regional anesthesia reduced cumulative OME consumption on day 1 (45.7±37.6 mg vs 25.5±19.8 mg, respectively, mean difference of -20.1 (95% CI -37.4 to -2.9) mg, p=0.023) and day 2 (64.5±60 mg vs 35.8±30.2 mg, respectively, mean difference of -28.7 (95% CI -55.9 to -1.43) mg, p=0.040). Interestingly, worst pain score and cumulative OME consumptions on day 2 were positively correlated with the APAIS (Pearson's correlation coefficient of 0.42 (p=0.003) and 0.39 (p=0.006), respectively). CONCLUSION Bilateral ultrasound-guided V2 and V3 combined nerves block reduces postoperative opioid consumption by about 50% in patients undergoing double-jaw surgery. TRIAL REGISTRATION NUMBER NCT05351151.
Collapse
Affiliation(s)
- Thomas Esquerré
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, University Hospital Centre Toulouse, Toulouse, France
| | - Marion Mure
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, University Hospital Centre Toulouse, Toulouse, France
| | - Vincent Minville
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, University Hospital Centre Toulouse, Toulouse, France
| | - Alice Prevost
- Department of Plastic and Maxillofacial Surgery, University Hospital Centre Toulouse, Toulouse, France
| | - Frédéric Lauwers
- Department of Plastic and Maxillofacial Surgery, University Hospital Centre Toulouse, Toulouse, France
| | - Fabrice Ferré
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, University Hospital Centre Toulouse, Toulouse, France
| |
Collapse
|
5
|
Stone AB, Zorrilla Vaca A, Lirk P, Gerner P, Vlassakov K. Anesthesia start time documentation accuracy where peripheral nerve block is the primary anesthetic. Reg Anesth Pain Med 2024:rapm-2024-105292. [PMID: 38642928 DOI: 10.1136/rapm-2024-105292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION When used as the primary anesthetic, nerve blocks are not billed as separate procedures. In this scenario, the anesthesia start (AStart) time should include the block procedural time. We measured how often AStart time was documented before the nerve block was placed in the preoperative area, and compared cases where a block team performed the nerve block and cases where the intraoperative anesthesia attending supervised the nerve block. We hypothesized that the involvement of a regional anesthesia team would lead to more accurate documentation of AStart. We also estimated the lost revenue due to inaccurate start time documentation. METHODS The study population were patients undergoing surgery with a peripheral nerve block as the primary anesthetic. For this analysis, AStart occurring less than 10 min before the in-operating room time was defined as potentially inaccurate. Lost potential revenue was estimated by taking the difference between the documented time of local anesthetic administration and the documented AStart time. RESULTS A total of 745 cases were analyzed. Overall, 439 cases (58%) cases were identified as having potentially inaccurate start times. There were higher rates of inaccurate AStart documentation by the block team (316/482, 65.5%) compared with blocks supervised by the in-room anesthesia attendings (123/263, 46.7%, p<0.001). Overall, the estimated loss in billable revenue during the study period was a total of $70 265. CONCLUSIONS The performance of primary regional anesthesia procedure by a block team increased the incidence of inaccurate documentation and uncaptured potential revenue. There is need for education about accurate nerve block documentation for anesthesiologists, especially when separate teams are used.
Collapse
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Andrés Zorrilla Vaca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Gerner
- Harvard Medical School, Boston, Massachusetts, USA
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Gupta RK, Pawa A. Beam me up, Scotty! Apple Vision Pro highlights how we could teleport ultrasound-guided regional anesthesia education into the future. Reg Anesth Pain Med 2024:rapm-2024-105424. [PMID: 38580337 DOI: 10.1136/rapm-2024-105424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/22/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amit Pawa
- Department of Anaesthesia, Guy's & St Thomas' Hospital, London, UK
- Department of Theatres, Anaesthesia and Perioperative Medicine, Cleveland Clinic London, London, UK
| |
Collapse
|
7
|
Piccolo CV, Skerritt CJ. Reply to: Pericapsular nerve group (PENG) block for early pain management of elderly patients with hip fracture: a single-center double-blind randomized controlled trial. Reg Anesth Pain Med 2024; 49:305. [PMID: 37586875 DOI: 10.1136/rapm-2023-104676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 08/18/2023]
|
8
|
Lin X, Liu CW, Chan DXH. In response. Reg Anesth Pain Med 2024; 49:305-306. [PMID: 37586876 DOI: 10.1136/rapm-2023-104718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Xufeng Lin
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | | | - Diana Xin Hui Chan
- Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
9
|
Moody AE, Miller ST, Tupinio MR, Newberry CM, Mangleson J, Swenson JD. Fascial plane approach to anesthetizing the radial, median, and ulnar nerves: an educational review. Reg Anesth Pain Med 2024; 49:285-288. [PMID: 37709512 DOI: 10.1136/rapm-2023-104794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023]
Abstract
Brachial plexus block provides effective anesthesia and analgesia for upper extremity surgery but requires injection of large anesthetic volumes near major vascular structures. Moreover, the extensive motor and sensory loss produced by plexus block often exceeds the neural distribution needed for corresponding surgical procedures.High-resolution ultrasound facilitates selective nerve blocks at nearly every level of the upper extremity. We present fascial plane injection techniques for selective radial, median, and ulnar nerve blocks. These techniques can be used to match sensory distribution with specific surgical procedures. They are performed using low anesthetic volumes and without proximity to nerves or vascular structures. In this article, fresh cadaver dissections with corresponding ultrasound images are used to demonstrate stepwise fascial plane techniques for the radial, median, and ulnar nerves. These techniques are performed using familiar anatomic landmarks.Practical applications of these techniques are demonstrated for commonly performed procedures of the upper extremity. Corresponding injection volumes with duration of postoperative analgesia are presented. Selected injections are described for both surgical anesthesia and postoperative analgesia.Selective fascial plane injections can provide surgical anesthesia and postoperative analgesia in settings that might otherwise require much larger volumes of local anesthetic. These selective nerve blocks can match sensory loss with the anatomic pain distribution in each patient. Reliable techniques for selective nerve blocks of the upper extremity can expand the capabilities for ultrasound-guided regional anesthesia.
Collapse
Affiliation(s)
- Alastair E Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Sarah T Miller
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Maegan R Tupinio
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Cynthia M Newberry
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - John Mangleson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey D Swenson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
10
|
Heo Y, Yang M, Nam SM, Lee HS, Kim YD, Won HS. New insight into the vasto-adductor membrane for safer adductor canal blockade. Korean J Pain 2024; 37:132-140. [PMID: 38433475 PMCID: PMC10985484 DOI: 10.3344/kjp.23292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 03/05/2024] Open
Abstract
Background : This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB). Methods : Fifty thighs from 25 embalmed adult Korean cadavers were used. The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base. All target points were measured perpendicular to the baseline. The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals. US-guided dye injection was performed to determine the ideal volume. Results : The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point. The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point. The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle. The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens. The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery. Conclusions : Confirming the crucial landmark, the VAM, is beneficial when performing ACB. It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient.
Collapse
Affiliation(s)
- Yanguk Heo
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Sarcopenia Total Solution Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Sung Min Nam
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyun Seung Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| |
Collapse
|
11
|
Ferreira-Silva N, Hurdle MFB, Clendenen SR, Gulati A, McLaughlin SA, Troyer W, Rosario-Concepción RA. Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome. Pain Pract 2024; 24:677-685. [PMID: 38170566 DOI: 10.1111/papr.13341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option. RESULTS This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome. CONCLUSION This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.
Collapse
Affiliation(s)
- Nuno Ferreira-Silva
- Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | | | | | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Wesley Troyer
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
| | | |
Collapse
|
12
|
Etheridge JPB, Finlayson RJ, Venter J, De Villiers F, Etheridge JP, Wakefield R, Watanitanon A. Prospective evaluation of the safety of ultrasound-guided cervical medial branch blocks using the in-plane technique. Reg Anesth Pain Med 2024:rapm-2024-105296. [PMID: 38508589 DOI: 10.1136/rapm-2024-105296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND While fluoroscopic guidance is currently the imaging standard for cervical medial branch blocks (CMBBs), ultrasound guidance (USG) offers several potential safety advantages such as real-time needle visualization and the ability to detect and avoid critical soft tissue vascular or neural structures. However, no large-scale trials have examined the safety of USG for CMBB. METHODS Five hundred patients undergoing 2308 individual block levels were recruited using a prospective cohort design, and blocks were performed in an outpatient office setting using an in-plane USG technique. Primary outcomes included immediate block-related complication, as well as delayed occurrences, in the following 2 weeks. Vascular structures adjacent to the target area, as well as the occurrence of vascular breach, were recorded. RESULTS Three minor immediate complications were noted (two subcutaneous hematomas, one vasovagal reaction) comprising 0.13% of blocks (0.03% to 0.38%; 95% two-sided CI), and no delayed events were recorded (0% to 0.16%; 97.5% one-sided CI). Blood vessels were detected and avoided in 8.2% of blocks, and vascular breach was noted in 0.52% of blocks (0.27% to 0.91%; 95% two-sided CI). CONCLUSION When performed using an in-plane technique by experienced operators, USG CMBB was found to be safe, with rare minor immediate complications and no further adverse event reported in the following 2 weeks. TRIAL REGISTRATION NUMBER NCT04852393.
Collapse
Affiliation(s)
| | - Roderick J Finlayson
- Bill Nelems Pain and Research Centre, Kelowna, British Columbia, Canada
- Department of Anesthesia, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jan Venter
- Bill Nelems Pain and Research Centre, Kelowna, British Columbia, Canada
| | | | | | - Reece Wakefield
- Bill Nelems Pain and Research Centre, Kelowna, British Columbia, Canada
| | | |
Collapse
|
13
|
Ata AM, Kesikburun B, Karamehmetoğlu M, Adıgüzel E. Ultrasound-guided erector spinae plane block in patients with chronic lumbar facet joint pain: A prospective case-controlled study. Pain Pract 2024. [PMID: 38459756 DOI: 10.1111/papr.13367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
PURPOSE The aim was to evaluate the efficacy of ultrasound-guided erector spinae plane (ESP) block and compare with the conventional physical therapy in chronic low back pain (LBP). MATERIALS AND METHODS This prospective case-controlled study included patients with chronic LBP. Their clinical and demographic data were obtained, and they were divided into two groups for conventional physical therapy and ESP blocks. Prior to treatment, on the first day, the second week, and the third month, the Oswestry Disability Index (ODI) and visual analog scale (VAS) pain score were evaluated. RESULTS The study included 43 patients, 21 in the ESP block group and 22 in the conventional physical therapy group. The VAS in movement was higher in the ESP block group at baseline (p = 0.047). On the first day after the treatments, the ESP block group showed lower resting (p < 0.001) and movement (p = 0.001) VAS values than the conventional physical therapy group. At the end of 3 months, both groups had improved VAS and ODI scores (all p < 0.001). CONCLUSION US-guided ESP block might be considered a successful, safe, and technically simple alternative treatment in patients with chronic LBP to control pain and reduce the cost of physical therapy and lost workdays.
Collapse
Affiliation(s)
- Ayşe Merve Ata
- Department of Physical Medicine and Rehabilitation, Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Bilge Kesikburun
- Department of Physical Medicine and Rehabilitation, Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Miray Karamehmetoğlu
- Department of Physical Medicine and Rehabilitation, Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| | - Emre Adıgüzel
- Department of Physical Medicine and Rehabilitation, Ankara Bilkent City Hospital, Physical Therapy and Rehabilitation Hospital, Ankara, Turkey
| |
Collapse
|
14
|
Smulders PS, Ten Hoope W, Baumann HM, Hermanides J, Hemke R, Beenen LFM, Oostra RJ, Marhofer P, Lirk P, Hollmann MW. Adductor canal block techniques do not lead to involvement of sciatic nerve branches: a radiological cadaveric study. Reg Anesth Pain Med 2024; 49:174-178. [PMID: 37399253 DOI: 10.1136/rapm-2022-104227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Low and high volume mid-thigh (ie, distal femoral triangle) and distal adductor canal block approaches are frequently applied for knee surgical procedures. Although these techniques aim to contain the injectate within the adductor canal, spillage into the popliteal fossa has been reported. While in theory this could improve analgesia, it might also result in motor blockade due to coverage of motor branches of the sciatic nerve. This radiological cadaveric study, therefore, investigated the incidence of coverage of sciatic nerve divisions after various adductor canal block techniques. METHODS Eighteen fresh, unfrozen and unembalmed human cadavers were randomized to receive ultrasound-guided distal femoral triangle or distal adductor canal injections, with 2 mL or 30 mL injectate volume, on both sides (36 blocks in total). The injectate was a 1:10 dilution of contrast medium in local anesthetic. Injectate spread was assessed using whole-body CT with reconstructions in axial, sagittal and coronal planes. RESULTS No coverage of the sciatic nerve or its main divisions was found. The contrast mixture spread to the popliteal fossa in three of 36 nerve blocks. Contrast reached the saphenous nerve after all injections, whereas the femoral nerve was always spared. CONCLUSIONS Adductor canal block techniques are unlikely, even when using larger volumes, to block the sciatic nerve, or its main branches. Furthermore, injectate reached the popliteal fossa in a small minority of cases, yet if a clinical analgesic effect is achieved by this mechanism is still unknown.
Collapse
Affiliation(s)
- Pascal Sh Smulders
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Holger M Baumann
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- Department of Medical Biology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Peter Marhofer
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Varela V, Ruíz C, Montecinos S, Prats-Galino A, Sala-Blanch X. Spread of local anesthetic injected in the paravertebral space, intertransverse processes space, and erector spinae plane: a cadaveric model. Reg Anesth Pain Med 2024; 49:228-232. [PMID: 37607803 DOI: 10.1136/rapm-2023-104342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/09/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Paraspinal fascial plane blocks have become popular and include the erector spinae plane (ESP) and intertransverse process (ITP) blocks. Controversy exists regarding the exact mechanism(s) of these blocks. We aimed to evaluate the spread of local anesthetic (LA) following ESP and ITP blocks as compared with paravertebral (PV) blocks in a cadaveric model. METHOD Single-injection ultrasound guided ESP (n=5), ITP (n=5), and PV (n=5) blocks were performed in 15 fresh cadaver hemithoraces. The extent of LA spread within the erector spinae fascial plane, involvement of the dorsal ramus, and distribution within the PV space, were qualitatively described. RESULTS The spread of LA following ESP block extended eight vertebral levels in a cranio-caudal direction, involving the dorsal ramus at each level, but without LA spread into the PV space nor to the ventral rami. LA spread following ITP block extended 1-2 vertebral levels within the PV space and 7 vertebral levels within the erector spinae fascial plane. The spread of LA following PV blocks extended 2-4 vertebral levels, involving the ventral and dorsal ramus at each level, but without LA spread into the ESP. CONCLUSION Based on the results of this cadaveric experimental model of paraspinal fascial plane blocks, LA spread following ITP blocks extends into both the PV space and the erector spine fascial plane, and thus may offer a more favorable analgesic profile than ESP blocks.
Collapse
Affiliation(s)
- Victor Varela
- Master in Advanced Medical Skills in Regional Anesthesia Based in Anatomy, University of Barcelona, Barcelona, Spain
| | - Carlos Ruíz
- Master in Advanced Medical Skills in Regional Anesthesia Based in Anatomy, University of Barcelona, Barcelona, Spain
| | | | | | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
- Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
| |
Collapse
|
16
|
Sørenstua M, Leonardsen ACL, Chin KJ. Dorsal root ganglion: a key to understanding the therapeutic effects of the erector spinae plane (ESP) and other intertransverse process blocks? Reg Anesth Pain Med 2024; 49:223-226. [PMID: 37726195 PMCID: PMC10958311 DOI: 10.1136/rapm-2023-104816] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/22/2023] [Indexed: 09/21/2023]
Abstract
Since its description in 2016, the erector spinae plane block (ESPB) has become a widely employed regional anesthetic technique and kindled interest in a range of related techniques, collectively termed intertransverse process blocks. There has been ongoing controversy over mechanism of action of the ESPB, mainly due to incongruities between results of cutaneous sensory testing, clinical efficacy studies, and investigations into the neural structures that are reached by injected local anesthetic (LA). This paper reviews the spread of LA to the paravertebral and epidural space and the cutaneous anesthesia in ESPB, with specific emphasis on the dorsal root ganglion (DRG). We hypothesize that the DRG, due to its unique and complex microarchitecture, represents a key therapeutic target for modulation of nociceptive signaling in regional anesthesia. This paper discusses how the anatomical and physiological characteristics of the DRG may be one of the factors underpinning the clinical analgesia observed in ESPB and other intertransverse process blocks.
Collapse
Affiliation(s)
- Marie Sørenstua
- Department of Anesthesia, Sykehuset Østfold HF, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ann-Chatrin Linqvist Leonardsen
- Department of Anesthesia, Sykehuset Østfold HF, Grålum, Norway
- Health and Welfare, Østfold University College, Fredrikstad, Norway
| | - Ki Jinn Chin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Harbell MW, Langley NR, Seamans DP, Kraus MB, Carey FJ, Craner RC. Deep parasternal intercostal plane nerve block: an anatomical study. Reg Anesth Pain Med 2024; 49:179-183. [PMID: 37419507 DOI: 10.1136/rapm-2023-104716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/22/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ultrasound-guided DPIP block in a human cadaveric model. METHODS Five ultrasound-guided DPIP blocks were performed in four unembalmed human cadavers using an in-plane approach with a linear transducer oriented in a transverse plane adjacent to the sternum. Twenty milliliters of 0.1% methylene blue were injected between ribs 3 and 4 into the plane deep to the internal intercostal muscles and superficial to the transversus thoracis muscle layer. The chest muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and mediolateral directions. RESULTS The transversus thoracis muscle slips were stained in all cadavers from 4 to 6 levels. Intercostal nerves were dyed in all specimens. Four levels of intercostal nerves were dyed in each specimen with variability in number of levels stained above and below the level of the injection. CONCLUSIONS The DPIP block spreads along the tissue plane above the transversus thoracis muscles to multiple levels to dye the intercostal nerves in this cadaver study. This block may be of clinical value for analgesia in anterior thoracic surgical procedures.
Collapse
Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Natalie R Langley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David P Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Molly B Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Frederick J Carey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
18
|
Bungart B, Joudeh L, Fettiplace M. Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:209-222. [PMID: 37451826 PMCID: PMC10787820 DOI: 10.1136/rapm-2023-104667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND/IMPORTANCE Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity. OBJECTIVE We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults. EVIDENCE REVIEW We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia. CONCLUSION Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.
Collapse
Affiliation(s)
- Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Mejia J, Goffin P, Reina MA, Sala-Blanch X. No evidence of fascicular injury following a low-volume intraneural injection of the median nerve: a cadaveric study. Reg Anesth Pain Med 2024:rapm-2024-105294. [PMID: 38418409 DOI: 10.1136/rapm-2024-105294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The test dose or hydrolocation technique allows rapid detection of spread location. Though its primary aim is to enhance safety in peripheral nerve blocks, evidence on the potential risks of an intraneural test aliquot is lacking. We conducted a cadaveric study to evaluate the risk of fascicular injury following a low-volume (<1 mL) intraneural injection of the median nerve. METHODS Ten upper limbs from fresh unembalmed human cadavers were studied. In-plane ultrasound-guided intraneural injections of the median nerve were performed at mid, proximal, and distal locations using 1 mL of methylene blue and heparinized blood solution. Nerves were extracted and samples immersed in 10% buffered formalin for 4 weeks. Perpendicular 3 mm slices were obtained for H&E staining and light microscopy analysis. Our main objective was to assess the number of injured fascicles. Secondarily, we evaluated the pattern of intraneural spread. Fascicular injury was defined as the presence perineurium or axonal disruption and/or the presence of erythrocytes inside a nerve fascicle. RESULTS Thirty injections were performed in 10 median nerves. Sonographic swelling was confirmed in 100% of the cases. 352 histological sections were analyzed to assess study outcomes. The mean number of fascicles on each section of median nerve was 20±6 covering 49%±7% of the nerve area. No evidence of axonal disruption nor intra-fascicular erythrocytes was found in any of the analyzed sections. CONCLUSIONS Low-volume intraneural injections do not result in evident fascicular injury. Our findings support the use of a test dose in ultrasound-guided regional anesthesia.
Collapse
Affiliation(s)
- Jorge Mejia
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Pierre Goffin
- Anesthesia and Intensive Care, CHC de Liège, Liège, Belgium
| | - Miguel A Reina
- Department of Anesthesiology, CEU San Pablo University Faculty of Medicine, Madrid, Spain
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
- Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
| |
Collapse
|
20
|
McLeod GA, Reina MA. Response to: are human nerve fascicles really impenetrable? Reg Anesth Pain Med 2024:rapm-2024-105394. [PMID: 38409263 DOI: 10.1136/rapm-2024-105394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Graeme A McLeod
- Imaging Science & Technology, University of Dundee, Dundee, UK
- School of Engineering and Physical Sciences, Heriot-Watt University, Edinburgh, UK
| | - Miguel Angel Reina
- Department of Anesthesiology, Faculty of Medicine, CEU San Pablo University, Madrid, Spain
- University of Florida, Gainesville, Florida, USA
| |
Collapse
|
21
|
Chung SM, Wang JC, Lin CR, Liu SC, Wu PT, Kuan FC, Fang CJ, Tu YK, Hsu KL, Lai PC, Shih CA. Beyond traditional therapies: a network meta-analysis on the treatment efficacy for chronic phantom limb pain. Reg Anesth Pain Med 2024:rapm-2023-105104. [PMID: 38388020 DOI: 10.1136/rapm-2023-105104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/24/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Phantom limb pain (PLP) frequently affects individuals with limb amputations. When PLP evolves into its chronic phase, known as chronic PLP, traditional therapies often fall short in providing sufficient relief. The optimal intervention for chronic PLP remains unclear. OBJECTIVE The objectives of this network meta-analysis (NMA) were to examine the efficacy of different treatments on pain intensity for patients with chronic PLP. EVIDENCE REVIEW We searched Medline, EMBASE, Cochrane CENTRAL, Scopus, and CINAHL EBSCO, focusing on randomized controlled trials (RCTs) that evaluated interventions such as neuromodulation, neural block, pharmacological methods, and alternative treatments. An NMA was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was pain score improvement, and the secondary outcomes were adverse events. FINDINGS The NMA, incorporating 12 RCTs, indicated that neuromodulation, specifically repetitive transcranial magnetic stimulation, provided the most substantial pain improvement when compared with placebo/sham groups (mean difference=-2.9 points, 95% CI=-4.62 to -1.18; quality of evidence (QoE): moderate). Pharmacological intervention using morphine was associated with a significant increase in adverse event rate (OR=6.04, 95% CI=2.26 to 16.12; QoE: low). CONCLUSIONS The NMA suggests that neuromodulation using repetitive transcranial magnetic stimulation may be associated with significantly larger pain improvement for chronic PLP. However, the paucity of studies, varying patient characteristics across each trial, and absence of long-term results underscore the necessity for more comprehensive, large-scale RCTs. PROSPERO REGISTRATION NUMBER CRD42023455949.
Collapse
Affiliation(s)
- Sun-Mei Chung
- Mackay Memorial Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jui-Chien Wang
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Ren Lin
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shu-Cheng Liu
- Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ching-Ju Fang
- Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Pei-Chun Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-An Shih
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| |
Collapse
|
22
|
Herteleer M, Choquet O, Swisser F, Bernard N, Gasc A, Canovas F, Dagneaux L, Bringuier S, Capdevila X. Plantar compartment block for hallux valgus surgery: a proof-of-concept anatomic and clinical study. Reg Anesth Pain Med 2024:rapm-2023-105246. [PMID: 38373818 DOI: 10.1136/rapm-2023-105246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/08/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Hallux valgus surgery is associated with moderate to severe postoperative pain. We hypothesized that a plantar compartment block may be a good technique for postoperative analgesia. We describe an anatomic approach to ultrasound-guided plantar compartment block and assess the clinical efficacy of the block for outpatient surgery. METHODS The anatomic study was aimed to describe the plantar compartment, using both dissection methods and imaging, and to define a volume of local anesthetic. Patients scheduled for hallux valgus surgery with a popliteal sciatic nerve block, and combined plantar compartment and peroneal blocks were included in the clinical study. Data on attaining the criteria for rapid exit from the outpatient center, duration of sensory and analgesic block, visual analog scale (VAS) values for postoperative pain at rest and during movement, and the consumption of morphine as rescue analgesia were recorded. RESULTS Plane-by-plane dissections and cross-sections were done in five cadaveric lower limbs. The medial calcaneal nerve divides into medial plantar and lateral plantar nerves in the upper part of the plantar compartment. These nerves were surrounded by 5 mL of colored gelatin, and 10 mL of injectates dye spread to the medial calcaneal branches. Thirty patients (26 women) were included in the clinical study. There were no failures of surgical block. Ninety per cent of patients successfully passed functional testing for ambulatory exit from the center within 5 hours (25th-75th centiles, 3.8-5.5 hours). The median duration of plantar compartment sensory block was 17.3 hours (10.5-21.5 hours), and the first request for rescue analgesic was 11.75 hours (10.5-23 hours) after surgery. The median VAS score for maximum pain reported within the 48-hour period was 2 (1-6). Twelve patients received 2.5 mg (0-5 mg) of morphine on day 1. Patients were highly satisfied and no adverse events were noted. CONCLUSIONS This anatomic description of the ultrasound-guided plantar compartment block reported the injection area to target the medial and lateral plantar nerves with 5 mL of local anesthetic. Normal walking without assistance is attained rapidly with this regional anesthesia technique, and the time to request postoperative analgesia after hallux valgus surgery is long. TRIAL REGISTRATION NUMBER NCT03815422.
Collapse
Affiliation(s)
- Matthias Herteleer
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
- Department of Anatomy, Lille University School of Medicine, Lille, France
| | - Olivier Choquet
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Fabien Swisser
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Nathalie Bernard
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Audrey Gasc
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - François Canovas
- Department of Orthopedic Surgery and Traumatology, Lapeyronie University Hospital, Montpellier, France
- Department of Anatomy, Montpellier University School of Medicine, Montpellier, France
| | - Louis Dagneaux
- Department of Orthopedic Surgery and Traumatology, Lapeyronie University Hospital, Montpellier, France
- Department of Anatomy, Montpellier University School of Medicine, Montpellier, France
| | - Sophie Bringuier
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
- Department of Medical Statistics, Montpellier University Hospital, 34295 Montpellier Cedex 5, France and UMR UA11INSERM-UMIDESP, Montpellier University, Montpellier, France, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
- Inserm Unit 1298 Montpellier NeuroSciences Institute, Montpellier University, 34295 Montpellier Cedex 5, France
| |
Collapse
|
23
|
Orebaugh SL, Ligocki M. Are human nerve fascicles truly impenetrable? Reg Anesth Pain Med 2024:rapm-2024-105374. [PMID: 38355217 DOI: 10.1136/rapm-2024-105374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Steven L Orebaugh
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mariusz Ligocki
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
24
|
Ayyala HS, Assel M, Aloise J, Serafin J, Tan KS, Mehta M, Puttanniah V, McCormick P, Malhotra V, Vickers A, Matros E, Lin E. Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction. Reg Anesth Pain Med 2024:rapm-2023-105031. [PMID: 38336375 DOI: 10.1136/rapm-2023-105031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction. METHODS Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed. RESULTS 122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001). CONCLUSIONS Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.
Collapse
Affiliation(s)
- Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph Aloise
- Department of Operational Excellence, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joanna Serafin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghana Mehta
- Digital Informatics & Technology Solutions Department, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Patrick McCormick
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek Malhotra
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Evan Matros
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emily Lin
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
25
|
Jones A, Le-Wendling L, Ihnatsenka B, Smith C, Baker E, Boezaart A. Empirical guide to a safe thoracic paravertebral block based on dimensions of paravertebral space when ultrasound visualization is challenging. Reg Anesth Pain Med 2024; 49:133-138. [PMID: 37429621 DOI: 10.1136/rapm-2022-104181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/27/2023] [Indexed: 07/12/2023]
Abstract
Although ultrasound (US) guidance is the mainstay technique for performing thoracic paravertebral blocks, situations arise when US imaging is limited due to subcutaneous emphysema or extremely deep structures. A detailed understanding of the anatomical structures of the paravertebral space can be strategic to safely and accurately perform a landmark-based or US-assisted approach. As such, we aimed to provide an anatomic roadmap to assist physicians. We examined 50 chest CT scans, measuring the distances of the bony structures and soft-tissue surrounding the thoracic paravertebral block at the 2nd/3rd (upper), 5th/6th (middle), and 9th/10th (lower) thoracic vertebral levels. This review of radiology records controlled for individual differences in body mass index, gender, and thoracic level. Midline to the lateral aspect of the transverse process (TP), the anterior-to-posterior distance of TP to pleura, and rib thickness range widely based on gender and thoracic level. The mean thickness of the TP is 0.9±0.1 cm in women and 1.1±0.2 cm in men. The best target for initial needle insertion from the midline (mean length of TP minus 2 SDs) distance would be 2.5 cm (upper thoracic)/2.2 cm (middle thoracic)/1.8 cm (lower thoracic) for females and 2.7 cm (upper)/2.5 cm (middle)/2.0 cm (lower thoracic) for males, with consideration that the lower thoracic region allows for a lower margin of error in the lateral dimension because of shorter TP. There are different dimensions for the key bony landmarks of a thoracic paravertebral block between males and females, which have not been previously described. These differences warrant adjustment of landmark-based or US-assisted approach to thoracic paravertebral space block for male and female patients.
Collapse
Affiliation(s)
- Anastasia Jones
- Anesthesiology, University of Florida, Gainesville, Florida, USA
- Anesthesiology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Barys Ihnatsenka
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Cameron Smith
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Erik Baker
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Andre Boezaart
- Anesthesiology, University of Florida, Gainesville, Florida, USA
- Lumina Health, Surrey, UK
| |
Collapse
|
26
|
Lemke E, Johnston DF, Behrens MB, Seering MS, McConnell BM, Swaran Singh TS, Sondekoppam RV. Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance. Reg Anesth Pain Med 2024; 49:122-132. [PMID: 37940348 DOI: 10.1136/rapm-2023-104855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed. OBJECTIVE In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance. EVIDENCE REVIEW A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion. FINDINGS The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block. CONCLUSIONS Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.
Collapse
Affiliation(s)
- Ethan Lemke
- Emergency Medicine, University of Michigan Health-West, Wyoming, Michigan, USA
| | - David F Johnston
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Matthew B Behrens
- Department of Emergency Medicine, Kent Hospital, Warwick, Rhode Island, USA
| | - Melinda S Seering
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
| | - Brie M McConnell
- Davis Library, University of Waterloo, Waterloo, Ontario, Canada
| | | | | |
Collapse
|
27
|
Livesey L, DeGraves F, Allred C, Boone L, Schumacher J. The efficacy of injecting a distillate of the pitcher plant (Sarraceniaceae) adjacent to the palmar digital nerves of horses to ameliorate lameness caused by digital pain. J Equine Vet Sci 2024; 133:104974. [PMID: 38145776 DOI: 10.1016/j.jevs.2023.104974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/19/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
This study aimed to determine the efficacy of instilling extract of the pitcher plant around the palmar digital nerves of horses to ameliorate digit pain causing lameness. Five mixed breed horses were recruited. Horses were determined to be lame because of pain in the distal portion of one or both thoracic limbs by a positive response to a basisesamoid nerve block using 2%^mepivacaine hydrochloride. Gait was evaluated pre- and post-nerve block at 30 min, 3, 7,14 and 21 days. At the 3-week evaluation, the basisesamoid nerve block was repeated using the extract, and the gait was evaluated at similar times. Lameness was evaluated objectively using a wireless, inertial, sensor-based, motion analysis system. The basisesamoid nerve block significantly ameliorated lameness at 30 min when gait was evaluated, but it had no significant effect on lameness after this time. The product containing extract of the pitcher plant had no significant effect on lameness when administered as a basisesamoid nerve block at any time. Extract of the pitcher plant administered adjacent to the medial and lateral palmar digital nerves (i.e., a basisesamoid nerve block) had no efficacy in ameliorating lameness in the distal portion of one or both thoracic limbs. Extract of the pitcher plant likely has no value for treating horses for chronic pain when administered as a regional nerve block.
Collapse
Affiliation(s)
- Leanda Livesey
- Department of Clinical Sciences, College of Veterinary Medicine, Tuskegee University, AL 36088 (Livesey, Allred).
| | - Fred DeGraves
- Department of Agriculture and Food Science, Ogden College of Science and Engineering, Western Kentucky University, Bowling Green, KY 42101, DeGraves
| | - Courtney Allred
- Department of Clinical Sciences, College of Veterinary Medicine, Tuskegee University, AL 36088 (Livesey, Allred)
| | - Lindsey Boone
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, AL 36849, (Boone, Schumacher)
| | - John Schumacher
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, AL 36849, (Boone, Schumacher)
| |
Collapse
|
28
|
Osuchukwu O, Gagnon J, Richard J, Craig W, Quaye A. Liposomal bupivacaine in transversus abdominis plane blocks for lower abdominal surgery. Pain Pract 2024. [PMID: 38265273 DOI: 10.1111/papr.13347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Transversus abdominis plane blocks are an established method of postoperative analgesia for abdominopelvic surgeries. Liposomal bupivacaine is an extended-release formulation of bupivacaine providing up to 72 h of analgesia. This study aims to determine if transversus abdominis plane blocks performed with liposomal bupivacaine are associated with reduced opioid consumption and level of pain intensity compared to conventional bupivacaine in patients undergoing lower abdominal surgery. METHODS This retrospective cohort study was conducted at a single institution between December 2020 and December 2021. After institutional review board approval, we identified patients who underwent lower abdominopelvic surgery with transversus abdominis plane blocks done with liposomal or conventional bupivacaine and collected demographic, clinical, and procedural information for analysis. We compared total opioid consumption over 72-h postoperatively in milligram morphine equivalents (MME), frequency of opioid utilization, and average level of pain intensity between groups. These outcomes were also evaluated after adjusting for covariates. Data were presented as mean ± SD, median [IQR] or frequency (%), as appropriate; p < 0.05 was accepted as significant. RESULTS A total of 178 patients met inclusion criteria, with 79 patients receiving an admixture of liposomal bupivacaine and conventional bupivacaine and 99 patients receiving conventional bupivacaine. The liposomal bupivacaine group had a median opioid consumption 72-h postoperatively of 47.5 [18-91.8] MME compared to 88 [43.8-160] MME in the conventional bupivacaine group, p = 0.045. Differences in opioid consumption between the groups did not reach statistical significance after adjustment for demographic and clinical characteristics, p = 0.11. There was no significant difference in frequency of opioid use or average pain intensity. CONCLUSION Transversus abdominis plane blocks using an admixture of liposomal bupivacaine conventional bupivacaine are not associated with decreased opioid consumption or reduced pain up to 72 h following elective abdominopelvic surgery.
Collapse
Affiliation(s)
- Obiyo Osuchukwu
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine, USA
| | - James Gagnon
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine, USA
- Spectrum Healthcare Partners, South Portland, Maine, USA
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine, USA
| | - Wendy Craig
- MaineHealth Institute for Research, Scarborough, Maine, USA
| | - Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine, USA
- Spectrum Healthcare Partners, South Portland, Maine, USA
| |
Collapse
|
29
|
Hurley NC, Gupta RK, Schroeder KM, Hess AS. Danger, Danger, Gaston Labat! Does zero-shot artificial intelligence correlate with anticoagulation guidelines recommendations for neuraxial anesthesia? Reg Anesth Pain Med 2024:rapm-2023-104868. [PMID: 38253610 DOI: 10.1136/rapm-2023-104868] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/18/2023] [Indexed: 01/24/2024]
Abstract
INTRODUCTION Artificial intelligence and large language models (LLMs) have emerged as potentially disruptive technologies in healthcare. In this study GPT-3.5, an accessible LLM, was assessed for its accuracy and reliability in performing guideline-based evaluation of neuraxial bleeding risk in hypothetical patients on anticoagulation medication. The study also explored the impact of structured prompt guidance on the LLM's performance. METHODS A dataset of 10 hypothetical patient stems and 26 anticoagulation profiles (260 unique combinations) was developed based on American Society of Regional Anesthesia and Pain Medicine guidelines. Five prompts were created for the LLM, ranging from minimal guidance to explicit instructions. The model's responses were compared with a "truth table" based on the guidelines. Performance metrics, including accuracy and area under the receiver operating curve (AUC), were used. RESULTS Baseline performance of GPT-3.5 was slightly above chance. With detailed prompts and explicit guidelines, performance improved significantly (AUC 0.70, 95% CI (0.64 to 0.77)). Performance varied among medication classes. DISCUSSION LLMs show potential for assisting in clinical decision making but rely on accurate and relevant prompts. Integration of LLMs should consider safety and privacy concerns. Further research is needed to optimize LLM performance and address complex scenarios. The tested LLM demonstrates potential in assessing neuraxial bleeding risk but relies on precise prompts. LLM integration should be approached cautiously, considering limitations. Future research should focus on optimization and understanding LLM capabilities and limitations in healthcare.
Collapse
Affiliation(s)
- Nathan C Hurley
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Aaron S Hess
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| |
Collapse
|
30
|
Maagaard M, Andersen JH, Jaeger P, Mathiesen O. Effects of combined dexamethasone and dexmedetomidine as adjuncts to peripheral nerve blocks: a systematic review with meta-analysis and trial sequential analysis. Reg Anesth Pain Med 2024:rapm-2023-105098. [PMID: 38253609 DOI: 10.1136/rapm-2023-105098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND/IMPORTANCE The effects of combining dexamethasone and dexmedetomidine on block duration are unclear. OBJECTIVE To investigate the effects of combining dexamethasone and dexmedetomidine on block duration. EVIDENCE REVIEW Systematic review of randomized controlled trials (RCTs) from Medline, Embase, CENTRAL, CINAHL, the Web of Science, and BIOSIS until June 8, 2023. RCTs with adults undergoing surgery with a peripheral nerve block randomized to combined dexamethasone and dexmedetomidine versus placebo or other adjuncts were eligible. Primary outcome was duration of analgesia. We performed meta-analysis, trial sequential analysis, risk of bias-2, and Grading Recommendations Assessment, Development, and Evaluation assessment. FINDINGS We included 9 RCTs with 14 eligible comparisons. The combination of dexamethasone and dexmedetomidine was compared with placebo in three RCTs (173 participants), dexamethasone in seven (569 participants), and dexmedetomidine in four (281 participants). The duration of analgesia was likely increased with the combination versus placebo (mean difference 460 min, 95% CI 249 to 671) and versus dexmedetomidine (mean difference 388 min, 95% CI 211 to 565). The duration was likely similar with the combination versus dexamethasone (mean difference 50 min, 95% CI -140 to 239). The certainty of the evidence was moderate because most trials were at high risk of bias. CONCLUSIONS Combined dexamethasone and dexmedetomidine likely increased the duration of analgesia when compared with placebo and dexmedetomidine. The combination likely provided a similar duration of analgesia as dexamethasone. Based on this systematic review, it seems reasonable to use dexamethasone as the sole adjunct if the goal is to increase the duration of analgesia.
Collapse
Affiliation(s)
| | | | - Pia Jaeger
- Department of Anaesthesia, the Juliane Marie Centre, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Ole Mathiesen
- Anaesthesiology, Zealand University Hospital, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
31
|
Kim SH, Yeo IS, Jang J, Jung HE, Chun YM, Yang HM. Infraspinatus-teres minor (ITM) interfascial block: a novel approach for combined suprascapular and axillary nerve block. Reg Anesth Pain Med 2024; 49:67-72. [PMID: 37491150 DOI: 10.1136/rapm-2023-104738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Combined suprascapular and axillary nerve block could be an analgesic option for shoulder pain control. The current description of this technique requires performing the block procedures at two different sites without consideration for catheter placement. We hypothesized that a single site injection to the interfascial plane between the infraspinatus and teres minor would result in an injectate spread to the suprascapular and axillary nerves. METHODS We performed 10 injections with this approach using 25 mL dye solution in 10 shoulders of five unembalmed cadavers. Also, we described three case reports, two single-injection cases and one catheter-placement case, using this approach in patients with acute postsurgical pain and chronic pain in their shoulder region. RESULTS In cadaveric evaluations, dye spreading to the suprascapular nerves on the infraspinatus fossa and the spinoglenoid notch cephalad and axillary nerves in the quadrilateral space caudally were observed in all injections. In addition, the most posterolateral part of the joint capsule was stained in 8 out of 10 injections. There was no dye spreading on the nerves to the subscapularis or lateral pectoral nerves. Clinically successful analgesia with no adverse events was achieved in all three cases. CONCLUSION Our anatomical and clinical observations demonstrated that an injection to the interfascial plane between the infraspinatus and teres minor consistently achieved injectate spreading to both suprascapular and axillary nerves, which innervate the glenohumeral joint.
Collapse
Affiliation(s)
- Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - In-Seung Yeo
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anatomy, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Jaewon Jang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Hyun Eom Jung
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Hun-Mu Yang
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anatomy, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| |
Collapse
|
32
|
Gessner D, Tsui BCH, Horn JL. Performance of the Pain Sensitivity Questionnaire short form in outpatient arthroscopic surgery without preoperative peripheral nerve block: a prospective observational cohort study. Reg Anesth Pain Med 2024; 49:74-76. [PMID: 36270751 DOI: 10.1136/rapm-2022-103957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Daniel Gessner
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ban C H Tsui
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jean-Louis Horn
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
33
|
Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:59-66. [PMID: 37429620 PMCID: PMC10850837 DOI: 10.1136/rapm-2023-104666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND/IMPORTANCE Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. OBJECTIVE We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). EVIDENCE REVIEW We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. CONCLUSIONS Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.
Collapse
Affiliation(s)
- Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Boretsky
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Childrens Hospital, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Park I, Park JH, Shin HJ, Na HS, Koo BW, Ryu JH, Oh AY. Postoperative analgesic effects of the quadratus lumborum block in pediatric patients: a systematic review and meta-analysis. Korean J Pain 2024; 37:59-72. [PMID: 38123185 PMCID: PMC10764215 DOI: 10.3344/kjp.23268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
Background This study assessed the postoperative analgesic efficacy and safety of the quadratus lumborum block (QLB) in pediatric patients. Methods Electronic databases were searched for studies comparing the QLB to conventional analgesic techniques in pediatric patients. The primary outcome was the need for rescue analgesia 12 and 24 hours after surgery. Secondary outcomes covered the Face-Legs-Activity-Cry-Consolability Scale (FLACC) scores at various time points; parental satisfaction; time to the first rescue analgesia; hospitalization time; block execution time; block failure rates, and adverse events. Results Sixteen randomized controlled trials were analyzed involving 1,061 patients. The QLB significantly reduced the need for rescue analgesia both at 12 and 24 hours after surgery (12 hours, relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.01, 0.88; 24 hours, RR: 0.51; 95% CI: 0.31, 0.70). In case of 24 hours after surgery, type 1 QLB significantly reduced the need for rescue analgesia (RR: 0.56; 95% CI: 0.36, 0.76). The QLB also exhibited lower FLACC scores at 1 hour (standardized mean difference [SMD]: -0.87; 95% CI: -1.56, -0.18) and 6 hours (SMD: -1.27; 95% CI: -2.33, -0.21) following surgery when compared to non-QLB. Among QLBs, type 2 QLB significantly extended the time until the first rescue analgesia (SMD: 1.25; 95% CI: 0.84, 1.67). No significant differences were observed in terms of parental satisfaction, hospitalization time, block execution time, block failure, or adverse events between QLB and non-QLB groups. Conclusions The QLB provides non-inferior analgesic efficacy and safety to conventional methods in pediatric patients.
Collapse
Affiliation(s)
- Insun Park
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyon Park
- Department of Radiology, The Armed Forces Daejeon Hospital, Daejeon, Korea
| | - Hyun-Jung Shin
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo-Seok Na
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bon-Wook Koo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung-Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicines, Seoul, Korea
| | - Ah-Young Oh
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicines, Seoul, Korea
| |
Collapse
|
35
|
Lee EY, Won HS, Yang M, Kim H, Kim YD. Comparison of international medical costs for interventional pain treatment: a focus on Korea and Japan. Korean J Pain 2024; 37:51-58. [PMID: 38072796 PMCID: PMC10764213 DOI: 10.3344/kjp.23254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023] Open
Abstract
Background The rise in national health care costs has emerged as a global problem given the ever-aging population and rapid development of medical technology. The utilization of interventional pain management has, similarly, shown a continued rise worldwide. This study evaluates the differences in the medical costs in the field of interventional pain treatment (IPT) between two countries: Korea and Japan. Methods Korean medical insurance costs for 2019 related to pain management focused on IPT were compared to those of Japan. Purchasing power parity (PPP) was used to adjust the exchange rate differences and to compare prices in consideration of the respective societies' economic power. Results The cost of trigger point injections in Japan was 1.06 times higher than that of Korea, whereas the perineural and intraarticular injection prices were lower in Japan. The cost of epidural blocks was higher in Japan compared to Korea in both cervical/thoracic and lumbar regions. As for blocks of peripheral branches of spinal nerves, the cost of scapular nerve blocks in Japan was lower than that in Korea, given a PPP ratio 0.09. For nerve blocks in which fluoroscopy guidance is mandatory, the costs of epidurography in Japan were greater than those in Korea, given a PPP ratio 1.04. Conclusions This is the first comparative study focusing on the medical costs related to IPT between Korea and Japan, which reveals that the costs differed along various categories. Further comparisons reflecting more diverse countries and socio-economic aspects will be required.
Collapse
Affiliation(s)
- Eun Young Lee
- Health Insurance Review and Assessment Service, Gwangju, Korea
| | - Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Sarcopenia Total Solution Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| |
Collapse
|
36
|
Kwon HJ, Kim CS, Kim J, Kim S, Shin JY, Choi SS, Shin JW, Kim DH. Contralateral oblique view can prevent dural puncture in fluoroscopy-guided cervical epidural access: a prospective observational study. Reg Anesth Pain Med 2023; 48:588-593. [PMID: 37024268 DOI: 10.1136/rapm-2022-104297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Although the contralateral oblique (CLO) view at 50°±5° is clinically useful for cervical epidural access, no previous studies have confirmed its safety. This prospective observational study was conducted to assess the safety profile, including the risk of dural puncture, in fluoroscopically guided cervical epidural access using the CLO view. METHODS In cervical epidural access using the CLO view, the incidence of dural puncture was investigated as the primary outcome. Other intraprocedural complications, including intravascular entry, subdural entry, spinal cord injury and vasovagal injury, and postprocedural complications were investigated as secondary outcomes. Procedural variables including first-pass success, final success, needling time, total number of needle passes and false loss of resistance (LOR) were evaluated. RESULTS Of the 393 patients who underwent cervical interlaminar epidural access were included for analysis, no instances of dural puncture or spinal cord injury were observed. The incidence of intravascular entry, vasovagal reaction and subdural entry were 3.1%, 0.5% and 0.3%, respectively. All procedures were successfully performed, with 85.0% of first-pass success rate. The mean needling time was 133.8 (74.9) s. The false-positive and false-negative LOR rates were 8.2% and 2.0%, respectively. All needle tips were visualized clearly during the procedure. CONCLUSIONS The fluoroscopy-guided CLO view at 50°±5° avoided dural puncture or spinal cord injury and decreased the incidence of false LOR during cervical epidural access with a paramedian approach. TRIAL REGISTRATION NUMBER NCT04774458.
Collapse
Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chan-Sik Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsun Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sungwon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Young Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
37
|
Sivakumar RK, Karmakar MK, Reina MA, Sala-Blanch X. High-definition ultrasound imaging of the paraneural sheath and fascial compartments surrounding the brachial plexus at the supraclavicular fossa. Reg Anesth Pain Med 2023; 48:622-624. [PMID: 35973780 DOI: 10.1136/rapm-2022-103822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Ranjith Kumar Sivakumar
- Department of Anesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China
| | - Manoj Kumar Karmakar
- Department of Anesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China
| | - Miguel Angel Reina
- Department of Anesthesiology, Faculty of Medicine, CEU San Pablo University, Madrid, Spain
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Xavier Sala-Blanch
- Department of Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| |
Collapse
|
38
|
Vandenbrande J, Jalil H, Callebaut I, Stessel B. Response to Fu-Shan Xue's letter to the editor. Reg Anesth Pain Med 2023:rapm-2023-105044. [PMID: 38050165 DOI: 10.1136/rapm-2023-105044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/11/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Jeroen Vandenbrande
- Department of Anaesthesiology and Pain Medicine, Jessa Ziekenhuis vwz, Hasselt, Limburg, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Hassanin Jalil
- Department of Anaesthesiology and Pain Medicine, Jessa Ziekenhuis vwz, Hasselt, Limburg, Belgium
| | - Ina Callebaut
- Department of Anaesthesiology and Pain Medicine, Jessa Ziekenhuis vwz, Hasselt, Limburg, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Björn Stessel
- Department of Anaesthesiology and Pain Medicine, Jessa Ziekenhuis vwz, Hasselt, Limburg, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| |
Collapse
|
39
|
Balsevicius L, Urbano PCM, Hasselager RP, Mohamud AA, Olausson M, Svraka M, Wahlstrøm KL, Oppermann C, Gögenur DS, Hølmich ER, Cappelen B, Sækmose SG, Tanggaard K, Litman T, Børglum J, Brix S, Gögenur I. Effect of anterior quadratus lumborum block with ropivacaine on the immune response after laparoscopic surgery in colon cancer: a substudy of a randomized clinical trial. Reg Anesth Pain Med 2023:rapm-2023-104896. [PMID: 37945063 DOI: 10.1136/rapm-2023-104896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/21/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated. METHODS This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28. RESULTS Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05). CONCLUSIONS Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response.Trial registration number NCT03570541.
Collapse
Affiliation(s)
- Lukas Balsevicius
- Department of Surgery, Zealand University Hospital, Koge, Denmark
- Graduate School of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Paulo C M Urbano
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | - Rune Petring Hasselager
- Department of Surgery, Zealand University Hospital, Koge, Denmark
- Euro-Periscope, Onco-Anaesthesiology Research Group (RG), European Society of Anaesthesiology, Brussels, Belgium
| | | | - Maria Olausson
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | - Melina Svraka
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | | | | | | | | | - Britt Cappelen
- Department of Surgery, Zealand University Hospital, Koge, Denmark
| | | | - Katrine Tanggaard
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Thomas Litman
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Jens Børglum
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Brix
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Lyngby, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
40
|
Armaneous M, Du AL, Gabriel RA, Said ET. Association of thoracic epidural analgesia and hospital length of stay for patients undergoing thoracotomy: a retrospective cohort analysis. Reg Anesth Pain Med 2023:rapm-2023-104611. [PMID: 37940351 DOI: 10.1136/rapm-2023-104611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Regional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional anesthesia with time to hospital discharge for these patients. METHODS This was a retrospective cohort study using National Surgical Quality Improvement Program dataset from 2014 to 2020. Propensity-matched cohorts were assembled based on use of regional anesthesia, peripheral regional anesthesia, or epidural. Fine-Gray competing risk regressions were used to explore the association between regional anesthesia use and rate of discharge. The subdistribution hazard ratio (HR) represented relative discharge rates, and in-hospital death was a competing event. A sensitivity analysis was subsequently performed in which patients with American Society of Anesthesiologists score ≥4 were removed. RESULTS There were 4350 patients included in this analysis, in which 472 (10.8%) received a peripheral regional anesthesia nerve block and 565 (13.0%) received thoracic epidural analgesia. The subdistribution HR for rate of discharge in the epidural versus non-epidural cohort was 1.09 (95% CI 1.01 to 1.18), thus epidurals were associated with an increased rate of discharge over time. However, this benefit was no longer apparent with the sensitivity analysis. The subdistribution HR for rate of discharge in the peripheral regional anesthesia versus no regional anesthesia cohort was 1.26 (95% CI 1.15 to 1.39), thus peripheral regional anesthesia was associated with an increased rate of discharge over time. This benefit remained even with the sensitivity analysis. CONCLUSIONS Thoracic epidural use when compared with no regional anesthesia was associated with decreased length of stay following thoracotomy in our primary analysis. The difference was no longer apparent with the sensitivity analysis. Peripheral regional anesthesia was associated with decreased length of stay even after sensitivity analysis.
Collapse
Affiliation(s)
- Michael Armaneous
- Department of Anesthesiology, Riverside University Health System, Moreno Valley, CA, USA
| | - Austin L Du
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| |
Collapse
|
41
|
Nielsen MV, Tanggaard K, Bojesen S, Birkebæk ADLF, Therkelsen AS, Sørensen H, Klementsen C, Hansen C, Vazin M, Poulsen TD, Børglum J. Efficacy of the intertransverse process block: single or multiple injection? A randomized, non-inferiority, blinded, cross-over trial in healthy volunteers. Reg Anesth Pain Med 2023:rapm-2023-104972. [PMID: 37923346 DOI: 10.1136/rapm-2023-104972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION The intertransverse process block is increasingly used to ameliorate postoperative pain following a plethora of surgical procedures involving the thoracic wall. Nevertheless, the optimal approach and cutaneous extent of the sensory block are currently unknown. We aimed to further describe the intertransverse process block, single injection versus multiple injection, and we hypothesized that the single-injection intertransverse process block is a non-inferior technique. METHODS Twelve healthy male volunteers were cross-over randomized to receive either single-injection intertransverse process block with 21 mL ropivacaine 7.5 mg/mL, including two sham injections, at the thoracic level T4/T5 or multiple-injection intertransverse process block with three injections of 7 mL ropivacaine 7.5 mg/mL at the thoracic levels T2/T3, T4/T5 and T6/T7 at the first visit. At the second visit, the other technique was applied on the contralateral hemithorax. A non-inferiority margin of 1.5 anesthetized thoracic dermatomes was chosen. RESULTS The mean difference (95% CI) in the number of anesthetized thoracic dermatomes was 0.82 (-0.41 to 2.05) pnon-inf<0.01 indicating non-inferiority favoring the single-injection technique.Both techniques anesthetized the ipsilateral thoracic wall and demonstrated contralateral cutaneous involvement to a variable extent. The multiple-injection intertransverse process block anesthetized a significantly larger cutaneous area on the posterior hemithorax and decreased mean arterial pressure at 30 and 60 min postblock application. Thoracic thermography showed no intermodality temperature differences yet compared with baseline temperatures both techniques showed significant differences. CONCLUSIONS Single-injection intertransverse process block is non-inferior to multiple injection in terms of anesthetized thoracic dermatomes. Both techniques generally anesthetize the hemithoracic wall to a variable extent. EU CLINICAL TRIALS REGISTER 2022-501312-34-01.
Collapse
Affiliation(s)
- Martin Vedel Nielsen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Katrine Tanggaard
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Sophie Bojesen
- Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark
| | | | - Anne Sofie Therkelsen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Herman Sørensen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Cecilie Klementsen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Christian Hansen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Mojgan Vazin
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Troels Dirch Poulsen
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Jens Børglum
- Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| |
Collapse
|
42
|
de Oliveira LSG, Santiago Gomez R, Chaves RDA. Letter to editor in response to the recent publication: randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty. Reg Anesth Pain Med 2023; 48:578. [PMID: 36977530 DOI: 10.1136/rapm-2023-104499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Leonardo Saraiva Guimarães de Oliveira
- Postgraduation program in Sciences applied to Surgery and Ophthalmology, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Anesthesiology, Hospital Municipal Odilon Behrens, Belo Horizonte, Minas Gerais, Brazil
| | | | | |
Collapse
|
43
|
Xu L, Gessner D, Kou A, Kasimova K, Memtsoudis SG, Mariano ER. Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors: an infographic. Reg Anesth Pain Med 2023; 48:547-548. [PMID: 37173098 DOI: 10.1136/rapm-2023-104578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Lei Xu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Gessner
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Alex Kou
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Ksenia Kasimova
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
- Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
44
|
Kertkiatkachorn W, Ngarmukos S, Tanavalee A, Tanavalee C, Kampitak W. Intraoperative landmark-based genicular nerve block versus periarticular infiltration for postoperative analgesia in total knee arthroplasty: a randomized non-inferiority trial. Reg Anesth Pain Med 2023:rapm-2023-104563. [PMID: 37898482 DOI: 10.1136/rapm-2023-104563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/19/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Genicular nerve blocks (GNBs) are an emerging technique that have been used as a part of multimodal analgesia for total knee arthroplasty. The efficacy of intraoperative landmark-based GNBs, a recently introduced technique, has been established. We hypothesized that it would provide non-inferior postoperative analgesia compared with periarticular infiltration (PAI) when combined with continuous adductor canal block. METHODS This study randomized 140 patients undergoing total knee arthroplasty to receive either intraoperative landmark-based GNB (GNB group) or PAI (PAI group), with 139 completing the study. The primary outcomes were the pain scores at rest and during movement at 12 hours postoperatively on an 11-point Numerical Rating Scale; the non-inferiority margin was 1. Pain scores at additional time points, intravenous morphine consumption, time to first rescue analgesia, functional performance and muscle strength tests, and sleep disturbance were also assessed. RESULTS At 12 hours postoperatively, the PAI and GNB groups had median resting pain scores of 0 (0-2) and 0 (0-2), respectively. The median difference was 0 (95% CI -0.4 to 0.4, p=1), with the 95% CI upper limit below the prespecified non-inferiority margin. The median pain score during movement was 1.5 (0-2.3) and 2 (1-3.1) in the PAI and GNB groups, respectively. The median difference was 0.9 (95% CI 0.3 to 1.6, p=0.004), failing to demonstrate non-inferiority. The GNB group had higher intravenous morphine consumption at 12 hours postoperatively and a shorter time to first rescue analgesia. CONCLUSIONS GNB compared with PAI provides non-inferior resting pain relief. Non-inferiority was not established for pain during movement. TRIAL REGISTRATION NUMBER TCTR20220406001 (www.thaiclinicaltrials.org).
Collapse
Affiliation(s)
| | | | - Aree Tanavalee
- Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand
| | - Chottawan Tanavalee
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
45
|
Tsui BCH, Abboud SF. Negative trials as a compass. Reg Anesth Pain Med 2023:rapm-2023-105059. [PMID: 37890891 DOI: 10.1136/rapm-2023-105059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Steven F Abboud
- Anesthesiology, Stanford University, Stanford, California, USA
| |
Collapse
|
46
|
Tran J, Peng P, Ho L, von Schroeder H, Agur A. Innervation of thumb carpometacarpal joint: implications for diagnostic block and denervation procedures. Reg Anesth Pain Med 2023:rapm-2023-105009. [PMID: 37875348 DOI: 10.1136/rapm-2023-105009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/30/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a common disorder that negatively impacts hand function. Denervation of the thumb CMC joint has emerged as a viable treatment option. However, the innervation pattern of the thumb CMC joint is controversial. Therefore, the objective of this study was to identify the articular branches supplying the thumb CMC joint and to document their relationship to anatomical landmarks to provide the foundation for image-guided diagnostic block and denervation procedures. METHODS In 10 formalin-embalmed upper limb specimens articular branches supplying the thumb CMC joint were dissected from their origin to termination. A frequency map documenting the number of articular branches was generated. The frequency map enabled visualization and comparison of the relative area of innervation of the thumb CMC joint by each articular branch. RESULTS The thumb CMC joint received innervation from six nerves. These were the deep branch of ulnar nerve (DBUN), dorsal articular nerve (DAN) of the first interosseus space, thenar branch of median nerve (TBMN), palmar cutaneous branch of median nerve (PCBMN), lateral antebrachial cutaneous nerve (LACN) and superficial branch of the radial nerve (SBRN) and/or their branches. Each nerve was found to innervate different aspects of the joint. The DBUN and DAN were found to innervate the posteromedial aspect of the thumb CMC joint, the TBMN and PCBMN anterior/anteromedial aspects, LACN posterolateral/lateral/anterior aspects and SBRN posterolateral/anterolateral aspects. CONCLUSIONS The thumb CMC joint was innervated by articular branches originating from the SBRN, DAN, LACN, PCBMN, TBMN and DBUN. The documented anatomical relationships provide the foundation to inform selective diagnostic block and denervation of the thumb CMC joint. Further investigations are needed to assess the clinical implications of the current study.
Collapse
Affiliation(s)
- John Tran
- Division of Anatomy, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Medicine and Rehabilitation, Parkwood Institute, London, Ontario, Canada
| | - Philip Peng
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Loretta Ho
- Department of Anesthesiology and Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | | | - Anne Agur
- Division of Anatomy, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
47
|
Guerra ÂS, Barbosa MO, Oliveira MMDE, Coccoli RQ, Ganeo AAB, Sales EJF. THE EFFECTIVENESS OF FORAMINAL ROOT BLOCK IN RELIEVING SCIATIC PAIN DUE TO LUMBAR DISC HERNIATION. Acta Ortop Bras 2023; 31:e263169. [PMID: 37876867 PMCID: PMC10592337 DOI: 10.1590/1413-785220233105e263169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/22/2022] [Indexed: 10/26/2023]
Abstract
Objective To evaluate the clinical profile, pain improvement, and the need for surgical interventions in patients undergoing transforaminal block with the use of corticosteroids and anesthetics. Methods This is a prospective, randomized, double-blind study with 45 patients with unilateral radicular pain in their lower limbs and a single-segment lumbar disc herniation diagnosis. In the intervention group, transforaminal blocks with bupivacaine, dexamethasone, and clonidine were applied and in the control group, distilled water and bupivacaine. The Oswestry questionnaire was applied. Results We included 24 female (53.4%) and 21 male patients (46.6%). Of those with an occupation, 85.71% (n = 30) were relieved from their duties due to their illness and 14.29% (n = 5) continued to work with limitations. Those who underwent transforaminal block with an injection of corticosteroids, clonidine, and anesthetics showed immediate relief. However, such effect failed to alleviate patients' symptoms after three weeks. We observed that 52% of patients showed varying degrees of improvement. The control group experienced mild pain relief after one week, which also failed to last after three weeks. Moreover, 50% of patients improved in varying degrees. Conclusion Further studies with larger samples, new epidemiological data, and longer follow-ups are necessary to validate our hypotheses. Level of Evidence II, Prospective Study.
Collapse
|
48
|
Tsui BCH. Precision in nomenclature: blocks and injections. Reg Anesth Pain Med 2023:rapm-2023-104908. [PMID: 37852779 DOI: 10.1136/rapm-2023-104908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| |
Collapse
|
49
|
Affiliation(s)
- Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Dartmouth Health, Lebanon, New Hampshire, USA
| |
Collapse
|
50
|
Gleicher Y, Peacock S, Chin KJ. Case of phrenic sparing high thoracic erector spinae block for forequarter amputation. Reg Anesth Pain Med 2023; 48:531-532. [PMID: 36868586 DOI: 10.1136/rapm-2023-104383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/17/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Yehoshua Gleicher
- Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Anesthesia, Sinai Health, Toronto, Ontario, Canada
| | - Sharon Peacock
- Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Anesthesia, Sinai Health, Toronto, Ontario, Canada
| | - Ki Jinn Chin
- Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|