Articles: nerve-block.
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The epidural and subarachnoid spaces should be identified at the first attempt, since multiple punctures increase the risk of postdural puncture headache, epidural haematoma and neural trauma. The study aimed to describe the predictors of successful neuraxial blocks at the first attempt. ⋯ The successful location of the subarachnoid or the epidural space at the first attempt is influenced by the quality of patients' anatomical landmarks, the adequacy of patient positioning and the provider's level of experience.
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Randomized Controlled Trial Clinical Trial
Lumbar paravertebral nerve block in the management of pain after total hip and knee arthroplasty: a randomized controlled clinical trial.
The accepted mode of pain management after total hip or knee arthroplasty is patient-controlled analgesia. This study evaluates the efficacy of lumbar paravertebral nerve block in diminishing postoperative pain when used as an adjunct to patient-controlled analgesia. A total of 115 arthroplasty patients received postoperatively a lumbar paravertebral nerve block (block, n = 57) or a sham procedure (control, n = 58). ⋯ Visual analog scale pain score measurements at 4, 8, and 24 hours did not differ significantly between the groups. Paravertebral nerve block of the lumbar plexus is an invasive procedure with some risk. Considering the added risk and minimal benefits, routine use of this procedure is not supported.
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The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. ⋯ This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewParavertebral anaesthesia/analgesia for ambulatory surgery.
For many years, paravertebral nerve blockade has been an established technique for providing analgesia to the chest and abdomen. The current emphasis on containment of health care costs has resulted in a rediscovery of anaesthetic techniques, such as paravertebral blocks, that facilitate outpatient surgical management and promote early discharge. ⋯ Continuous paravertebral catheters, pharmacological agents used in PVB, and single versus multiple injection paravertebral block techniques are also covered. Specific clinical situations that are particularly well suited to the application of PVB as the primary anaesthetic in the ambulatory setting and other clinical situations where analgesia from PVB is efficacious are discussed.
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Anesthesia and analgesia · Jun 2002
Randomized Controlled Trial Clinical TrialContinuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation.
A computed tomographic scan was obtained in 35 patients to measure the depth and the relationship of the branches of the lumbar plexus to the posterior superior iliac spine projection and the vertebral column. In addition, we prospectively studied 80 patients scheduled for total hip arthroplasty who received a continuous psoas compartment block (CPCB) in the postoperative period. CPCB was performed after surgical procedures by using modified Winnie's landmarks and nerve stimulation. From 5 to 8 cm of catheter was inserted. Radiographs were obtained after injection of 10 mL of contrast medium. An initial loading dose (0.4 mL/kg) of 0.2% ropivacaine was injected, followed by continuous infusion of 0.2% ropivacaine for 48 h. The depth of the lumbar plexus and the distance between the lumbar plexus and the L4 transverse process were measured. Visual analog scale values of pain at 1, 12, 24, and 48 h were obtained at rest and during mobilization. Amounts of rescue analgesia were also recorded. Sensory blockade of the principal branches of the lumbosacral plexus was noted at 1 and 24 h, as were adverse events related to the technique. There was a significant difference between men and women in depth of the lumbar plexus (median values, 85 vs 70 mm for men and women, respectively). There was a positive correlation between the body mass index and skin-lumbar plexus distances. In contrast, there was no difference regarding the distance between the transverse process of L4 and the lumbar plexus. The catheter tip lay within the psoas major muscle in 74% of the patients and between the psoas and quadratus lumborum muscles in 22%. In three patients, the catheter was improperly positioned. At 1 h, sensory blockade of the femoral, obturator, and lateral femoral cutaneous nerves was successful in, respectively, 95%, 90%, and 85% of patients. At 24 h, these rates were 88%, 88%, and 83%, respectively. During the 48-h study period, median visual analog scale values of pain were approximately 10 mm at rest and from 18 to 25 mm during physiotherapy. Five patients received 5 mg of morphine at 1 h. Five cases of unilateral epidural anesthesia were noted after the bolus injection. We conclude that CPCB with 0.2% ropivacaine allows optimal analgesia after hip arthroplasty, with few side effects and a small failure rate. Before lumbar plexus branch stimulation and catheter insertion, anesthesiologists should be aware of the L4 transverse process location and lumbar plexus depth. ⋯ Lumbar plexus depth is correlated with the patient's body mass index and differs between men and women, but this is not true of the lumbar plexus-transverse process distance. Considering new landmarks, a continuous psoas compartment block promotes optimal analgesia after hip arthroplasty, with few side effects.