ABSTRACT
Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.
ABSTRACT
Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.
ABSTRACT
Background@#Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the “subcoracoid tunnel block.”Case: Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%). @*Conclusions@#Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brachial plexus cords.
ABSTRACT
Perioperative cardiac arrest is an unfortunate event that can have disastrous outcomes if not attended and intervened on time. Arrests occurring intraoperatively have usually good outcomes as the patient is continuously monitored and it is easy to find out the cause of cardiac arrest. Patients coming for emergency surgeries, advanced ASA physical status, extremes of age groups [geriatric, pediatric] are the candidates in which perioperative cardiac arrest occurs. Events precipitating cardiac arrests should be identified early in wards. However once an arrest occurs in wards, the overall outcome depends on the timing, efforts of the resuscitation team and the events leading to cardiac arrest
ABSTRACT
Patients with traumatic brain injury [TBI] require mechanical ventilation for airway protection, to reduce work of breathing, to reduce cerebral metabolic rate and to optimize intracerebral hemodynamics. Drugs like narcotics, benzodiazepines, propofol and alpha-2 agonists with or without non-depolarizing muscle relaxants are used to facilitate mechanical ventilation. We reviewed literature on search engines PubMed and Medline to determine the efficacy and feasibility of dexmedetomidine as the sole sedative agent in patients with TBI in terms of maintenance of hemodynamics, ease of neurological assessment with ongoing sedation and long term neurological outcome