ABSTRACT
Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine's commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.
Subject(s)
Brachial Plexus/anatomy & histology , Brachial Plexus/drug effects , Nerve Block/methods , Arm/innervation , HumansABSTRACT
BACKGROUND: It remains unclear whether local anesthetic concentration or total drug dose is the primary determinant of continuous peripheral nerve block effects. The only previous investigation, involving continuous popliteal-sciatic nerve blocks, specifically addressing this issue reported that insensate limbs were far more common with higher volumes of relatively dilute ropivacaine compared with lower volumes of relatively concentrated ropivacaine. However, it remains unknown if this relationship is specific to the sciatic nerve in the popliteal fossa or whether it varies depending on anatomic location. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates, but at an equal total basal dose, produces comparable effects when used in a continuous infraclavicular brachial plexus block. METHODS: Preoperatively, an infraclavicular catheter was inserted using the coracoid approach in patients undergoing moderately painful orthopedic surgery distal to the elbow. Patients were randomly assigned to receive a postoperative perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Both groups, therefore, received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. Our primary end point was the incidence of an insensate limb during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction. RESULTS: Patients given 0.4% ropivacaine (n = 27) experienced an insensate limb, a mean (sd) of 1.8 (1.6) times, compared with 0.6 (0.9) times for subjects receiving 0.2% ropivacaine (n = 23; estimated difference = 1.2 episodes, 95% confidence interval, 0.5-1.9 episodes; P = 0.001). Satisfaction with postoperative analgesia (scale 0-10, 10 = highest) was scored a median (25th-75th percentiles) of 10.0 (8.0-10.0) in Group 0.2% and 7.0 (5.3-8.9) in Group 0.4% (P = 0.018). Analgesia was similar in each group. CONCLUSIONS: For continuous infraclavicular nerve blocks, local anesthetic concentration and volume influence perineural infusion effects in addition to the total mass of local anesthetic administered. Insensate limbs were far more common with smaller volumes of relatively concentrated ropivacaine. This is the opposite of the relationship previously reported for continuous popliteal-sciatic nerve blocks. The interaction between local anesthetic concentration and volume is thus complex and varies among catheter locations.
Subject(s)
Amides/administration & dosage , Anesthetics, Local/administration & dosage , Brachial Plexus/drug effects , Clavicle/innervation , Nerve Block/methods , Orthopedic Procedures/adverse effects , Pain, Postoperative/prevention & control , Adult , Amides/adverse effects , Anesthetics, Local/adverse effects , Dose-Response Relationship, Drug , Drug Administration Schedule , Female , Humans , Infusion Pumps , Infusions, Parenteral , Male , Middle Aged , Ontario , Pain Measurement , Pain Threshold/drug effects , Pain, Postoperative/etiology , Patient Satisfaction , Ropivacaine , Single-Blind Method , Touch/drug effects , United StatesABSTRACT
The management of patients with coronary artery stents during the perioperative period is one of the most important patient safety issues clinicians confront. Perioperative stent thrombosis is a life-threatening complication for patients with either bare-metal or drug-eluting stents. Noncardiac surgery appears to increase the risk of stent thrombosis, myocardial infarction, and death, particularly when patients undergo surgery early after stent implantation. The incidence of complications is further increased when dual-antiplatelet therapy is discontinued preoperatively. It is generally agreed that aspirin must be continued throughout the perioperative period, except in circumstances when the risk of bleeding significantly outweighs the benefit of continued anticoagulation, such as procedures performed in a closed space. We present considerations for regional anesthesia, as well as postoperative recommendations as the occurrence of perioperative stent thrombosis appears to be greatest during this period. Immediate percutaneous coronary intervention is the definitive treatment for perioperative stent thrombosis, and 24-h access to an interventional cardiology suite should be readily available. Algorithms for perioperative management of patients with bare-metal and drug-eluting stents are proposed.
Subject(s)
Angioplasty, Balloon, Coronary , Coronary Vessels , Perioperative Care , Stents , Surgical Procedures, Operative , Anesthesia, Conduction , Aspirin/therapeutic use , Blood Loss, Surgical , Clopidogrel , Coronary Restenosis/prevention & control , Coronary Thrombosis/etiology , Coronary Thrombosis/prevention & control , Coronary Thrombosis/therapy , Humans , Platelet Aggregation Inhibitors/therapeutic use , Stents/adverse effects , Ticlopidine/analogs & derivatives , Ticlopidine/therapeutic useABSTRACT
BACKGROUND: It remains unknown whether local anesthetic concentration, or simply total drug dose, is the primary determinant of continuous peripheral nerve block effects. We therefore tested the null hypothesis that providing different concentrations and rates of ropivacaine, but at equal total doses, produces comparable effects when used in a continuous sciatic nerve block in the popliteal fossa. METHODS: Preoperatively, a perineural catheter was inserted adjacent to the sciatic nerve using a posterior popliteal approach in patients undergoing moderately painful orthopedic surgery at or distal to the ankle. Postoperatively, patients were randomly assigned to receive a perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Therefore, both groups received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. The primary end point was the incidence of an insensate limb, considered undesirable, during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction. RESULTS: Patients given 0.2% ropivacaine (n = 25) experienced an insensate limb with a mean (sd) of 1.8 (1.8) times, compared with 0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95% confidence interval, 0.3-2.0 episodes; P = 0.009). In contrast, analgesia and satisfaction were similar in each group. CONCLUSIONS: For continuous popliteal-sciatic nerve blocks, local anesthetic concentration and volume influence block characteristics. Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine. During continuous sciatic nerve block in the popliteal fossa, a relatively concentrated solution in smaller volume thus appears preferable.
Subject(s)
Amides/administration & dosage , Anesthetics, Local/administration & dosage , Infusion Pumps , Nerve Block , Pain, Postoperative/prevention & control , Sciatic Nerve , Adult , Aged , Ambulatory Surgical Procedures , Analgesia, Patient-Controlled , Analgesics, Opioid/therapeutic use , Female , Foot/surgery , Home Care Services, Hospital-Based , Humans , Male , Middle Aged , Orthopedic Procedures , Pain Measurement , Pain, Postoperative/drug therapy , Patient Satisfaction , RopivacaineSubject(s)
Analgesia, Epidural/adverse effects , Analgesics, Opioid/administration & dosage , Delayed-Action Preparations/adverse effects , Medical Errors/adverse effects , Morphine/administration & dosage , Postoperative Complications/chemically induced , Analgesics, Non-Narcotic/administration & dosage , Analgesics, Opioid/adverse effects , Anesthesia, General/methods , Anesthetics, Inhalation/administration & dosage , Delayed-Action Preparations/administration & dosage , Dexmedetomidine/administration & dosage , Electroencephalography , Female , Humans , Injections, Spinal/adverse effects , Isoflurane/administration & dosage , Middle Aged , Monitoring, Intraoperative/methods , Morphine/adverse effects , Naloxone/administration & dosage , Narcotic Antagonists/administration & dosage , Nitrous Oxide/administration & dosage , Ovary/surgery , Postoperative Complications/prevention & control , Recovery of Function/drug effects , Respiratory Insufficiency/prevention & control , Time FactorsABSTRACT
OBJECTIVE: Local anesthetic-induced cardiotoxicity remains a complication of regional anesthesia, with the potential to result in cardiac arrest refractory to resuscitation. Successful resuscitation using Intralipid (Baxter Pharmaceuticals by Fresenius Kabi, Uppsala, Sweden), has been reported in 2 patients with bupivacaine-induced cardiac arrest. CASE REPORT: We report another case for which Intralipid was used as part of a successful resuscitation in a patient with local anesthetic-induced cardiotoxicity. CONCLUSIONS: Early treatment with Intralipid may help prevent cardiac arrest and speed successful resuscitation efforts.
Subject(s)
Anesthetics, Local/adverse effects , Bupivacaine/adverse effects , Fat Emulsions, Intravenous/therapeutic use , Tachycardia, Ventricular/chemically induced , Tachycardia, Ventricular/therapy , Aged, 80 and over , Female , Heart Arrest/prevention & control , Humans , Resuscitation/methods , Time FactorsABSTRACT
BACKGROUND AND OBJECTIVES: It is currently unknown if the primary determinant of continuous peripheral nerve block effects is simply total drug dose, or whether local anesthetic concentration and/or volume have an influence. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates--but at an equal total basal dose--produces similar effects when used in a continuous interscalene nerve block. METHODS: Preoperatively, an anterolateral interscalene perineural catheter was inserted using the anterolateral approach in patients undergoing moderately painful shoulder surgery. Subjects were randomly assigned to receive a postoperative perineural infusion of either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Our primary endpoint was the incidence of an insensate hand/finger during the 24 hours beginning the morning following surgery. RESULTS: The incidence of an insensate hand/finger did not differ between the treatment groups (n = 50) to a statistically significant degree (0.2% ropivacaine, mean [SD] of 0.8 [1.3] times; 0.4% ropivacaine, mean 0.3 [0.6] times; estimated difference = 0.5 episodes, 95% confidence interval, -0.1 to 1.1 episodes; P = .080). However, this is statistically inconclusive given the confidence interval. In contrast, pain (P = .020) and dissatisfaction (P = .011) were greater in patients given 0.4% ropivacaine. CONCLUSIONS: For continuous interscalene nerve blocks, given the statistically inconclusive primary endpoint results and design limitations of the current study, further research on this topic is warranted. In contrast, providing a lower concentration of local anesthetic at a higher basal rate provided superior analgesia.
Subject(s)
Amides/administration & dosage , Analgesia, Patient-Controlled/methods , Anesthetics, Local/administration & dosage , Nerve Block/methods , Sensation/drug effects , Adolescent , Adult , Aged , Analgesics, Opioid/therapeutic use , Dose-Response Relationship, Drug , Female , Humans , Male , Middle Aged , Pain Measurement , Patient Satisfaction , Ropivacaine , Shoulder/surgery , Treatment Outcome , Young AdultABSTRACT
Several variations on the technique for infraclavicular brachial plexus block have been described. The coracoid infraclavicular technique has become popular because of easily identified landmarks, reliable distribution of blockade, and low risk of respiratory complications such as pneumothorax. We report a case of pneumothorax in a patient after a coracoid infraclavicular brachial plexus block. Subtleties in landmark identification and measurement may affect the risk of pneumothorax.
Subject(s)
Brachial Plexus , Clavicle , Nerve Block/adverse effects , Pneumothorax/diagnosis , Brachial Plexus/physiology , Humans , Male , Middle Aged , Pneumothorax/etiologyABSTRACT
Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51-70 PNBs (13%), 31-50 PNBs (20%), 11-30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.
Subject(s)
Academic Medical Centers/methods , Anesthesiology/methods , Anesthetics, Local/adverse effects , Cardiovascular Diseases/chemically induced , Data Collection , Anesthesia Department, Hospital/methods , Anesthesia, Local/adverse effects , Anesthesia, Local/methods , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/therapy , HumansABSTRACT
OBJECTIVES: Despite the tremendous growth of peripheral nerve blocks, no standard format exists to document their performance. Our objective was to create a peripheral nerve block form based on key elements of literature evidence and on our own group consensus. RESULTS: We describe the process and results of our multi-institutional effort to construct a standardized peripheral nerve block procedure form. CONCLUSION: A form was developed to help meet the medical, legal, and billing requirements of documentation consistent with the performance of peripheral nerve block.
Subject(s)
Medical Records/standards , Nerve Block/methods , Nerve Block/standards , Peripheral Nerves , Humans , Neurosurgical Procedures/methods , Neurosurgical Procedures/standards , Peripheral Nerves/physiologySubject(s)
Brachial Plexus , Nerve Block/methods , Arm/innervation , Arm/surgery , Brachial Plexus/anatomy & histology , HumansSubject(s)
Anticoagulants/adverse effects , Hematoma/etiology , Hematoma/pathology , Lumbosacral Plexus , Nerve Block/adverse effects , Retroperitoneal Space/pathology , Aged , Aged, 80 and over , Anterior Cruciate Ligament/surgery , Anterior Cruciate Ligament Injuries , Anticoagulants/therapeutic use , Arthroplasty, Replacement, Knee , Arthroscopy , Female , Humans , Knee/surgery , Magnetic Resonance Imaging , Male , Partial Thromboplastin Time , Thrombosis/prevention & controlSubject(s)
Nerve Block/methods , Anesthetics, Local/administration & dosage , Anesthetics, Local/adverse effects , Animals , Arm/innervation , Brachial Plexus/anatomy & histology , Brachial Plexus/physiology , Clonidine/pharmacology , Electric Stimulation Therapy/instrumentation , Epinephrine/pharmacology , Humans , Nerve Block/adverse effects , Peripheral Nervous System Diseases/etiology , Pneumothorax/etiologyABSTRACT
Anatomy favorable to the application of regional blockade, the capacity to decrease latency and prolong blockade, and the opportunity to facilitate recovery and decrease costs create a constellation of factors that have the potential to make upper extremity blockade a tremendously rewarding application of modern regional anesthetic technique. These rewards can be realized by the motivated anesthesiologist and shared with patients, surgical colleagues, and hospital administrators.
Subject(s)
Arm/innervation , Nerve Block/methods , HumansABSTRACT
This investigation was performed to determine the ability of a parturient to recall the pre-anesthesia discussion with her anesthesiologist and to determine if written consent added to this discussion improves recall. Eighty-two women presenting in labor were randomized to 'verbal' and 'verbal plus written' consent for epidural labor analgesia and were contacted 5 to 7 months after a pre-anesthetic interview. Ten objective questions were posed at this time that addressed issues that were 'true risks', 'false risks', and 'situational' issues related to the consent process. These responses were scored on a point scale so that a maximal objective recall score of 100 points was possible. Median recall score was 80 (70-90) in the 'verbal' group and 90 (80-100) in the 'verbal plus written' group. This difference was statistically significant (P< 0.01). In addition, three subjective questions were asked of all women at this time. All but six women (one 'verbal plus written' and five 'verbal' group patients) expressed that written consent would help them 'remember and appreciate the different anesthetic options, risks, and procedures'. Four of these same women (one 'verbal plus written' and three 'verbal' group patients) thought a written consent process was 'alarming'. Two of these same women (both 'verbal' group patients) reported that they felt unable to give informed consent.