Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Mar 2010
ReviewUltrasound-guided regional anesthesia and patient safety: An evidence-based analysis.
The role of ultrasound-guided regional anesthesia (UGRA) in reducing the frequency of regional anesthetic-related complications is difficult to ascertain from analyzing the limited literature on the topic. This evidence-based review critically evaluates the contributions of UGRA to improved patient safety, particularly as compared with standard nerve localization tools. Randomized controlled trials that compared UGRA with another form of neural localization and case series of more than 500 patients were used to compare safety parameters. ⋯ Statistical proof for meaningful reduction in the frequency of extremely rare complications, such as permanent peripheral nerve injury, is likely unattainable. Although there is evidence for UGRA reducing the occurrence of vascular puncture and the frequency of hemidiaphragmatic paresis, as yet there is at best inconclusive scientific proof that these surrogate outcomes are linked to actual reduction of their associated complications, such as local anesthetic systemic toxicity or predictable diaphragmatic impairment in at-risk individuals. This evidence-based review thus strives to summarize both the power and the limitations of UGRA as a tool for improving patient safety.
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Reg Anesth Pain Med · Mar 2010
ReviewThe effect of stimulating versus nonstimulating catheter techniques for continuous regional anesthesia: a semiquantitative systematic review.
Stimulating catheters provide feedback regarding the location of the catheter tip in relation to the target nerve or plexus. There is debate concerning whether stimulating catheters may reduce the failure rate of postoperative analgesia or whether they may enhance functional recovery by providing superior and more reliable postoperative analgesia. ⋯ Published reports of randomized controlled trials provide evidence for a better analgesic effect from stimulating catheters. Future trials should be conducted in a standardized manner with uniform reporting of outcomes, which may facilitate future quantitative analysis.
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Severe, systemic local anesthetic toxicity is arguably the most feared complication of regional anesthesia. A combination of old and new therapies is recommended to reduce the morbidity and mortality of symptomatic local anesthetic overdose. Prevention remains the criterion standard for improving patient safety during regional anesthesia. ⋯ Lipid infusion should be considered early, and the treating physician should be familiar with the method. We also recommend avoiding vasopressin and using epinephrine only in small doses. Vigilance, preparedness, and quick action will improve outcomes of this dreaded complication.
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To summarize the existing evidence behind the role of ultrasonography in neuraxial anesthesia techniques. ⋯ Neuraxial ultrasonography has been recently introduced to regional anesthesia practice. The limited data available to date suggest that it is a useful adjunct to physical examination, allowing for a highly precise identification of regional landmarks and a precise estimation of epidural space depth, thus facilitating epidural catheter insertion. Further research is needed to conclusively establish its impact on procedure success and safety profile, particularly in the adult nonobstetric population.
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Reg Anesth Pain Med · Mar 2010
ReviewThe ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: Executive summary.
The American Society of Regional Anesthesia and Pain Medicine charged an expert panel to examine the evidence basis for ultrasound guidance as a nerve localization tool in the clinical practices of regional anesthesia and interventional pain medicine. ⋯ Ultrasound guidance improves block characteristics (particularly performance time and surrogate measures of success) that are often block specific and that may impart an efficiency advantage depending on individual practitioner circumstances. Evidence for UGRA impacting patient safety is currently limited to the demonstration of improvements in the frequency of surrogate events for serious complications.