Continuous Nerve Block Research Articles

Continuous intercostal nerve block for pain relief after thoracotomy

Others have demonstrated the effectiveness of intercostal analgesia with bupivacaine hydrochloride (Marcain Plain; Astra). We present a greatly simplified method of effecting this. Our method is dependent on an intact pleura. To date, we have utilized this technique in 81 patients. Seventy-five (92.6%) required no additional analgesic in the first 24 hours following operation and 66 (81.5%), in the subsequent four days. Only 2 patients had postoperative pulmonary complications. No complication related either to the procedure or to the infusion of bupivacaine occurred. The technique as described here is a safe and reliable method of providing analgesia without any side effects after thoracotomy.

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Extrapleural bupivacaine for amelioration of multiple rib fracture pain.

The pain associated with multiple rib fractures can be surprisingly variable. The objective of this study was to determine the efficacy of an indwelling, percutaneously placed intercostal catheter in relieving the pain associated with multiple rib fractures. Prospective nonrandomized study setting: Surgical intensive care unit in a level 1 trauma center. Fifteen blunt chest trauma patients with a minimum of three rib fractures who had failed an intravenous patient controlled analgesia protocol. Insertion of an epidural catheter within the intercostal space. Bupivacaine 0.25% with epinephrine was injected in a volume of 20 mL. Subsequent doses were limited to a total of 400 mg per 24 hours. Severity of injury was estimated by using the Injury Severity Score. For each patient a preinjection visual analogue scale (VAS) and incentive spirometry (IS) lung volume were determined. Fifteen minutes following injection of 0.25% bupivacaine with epinephrine the VAS and IS were repeated. The Injury Severity Score ranged from 9 to 32 (mean 19.0 +/- 1.6). Overall, mean VAS pain scores improved significantly following the initial bolus of bupivacaine (before VAS = 7.5 +/- 0.6, after VAS = 3.5 +/- 0.5, p < 0.05) and this was associated with significant increase in IS lung volumes (before IS = 0.77 +/- 0.09, after IS = 1.3 +/- 0.13, p < 0.05). No patient experienced either insertion-related or drug administration complications. These results confirm that an indwelling intercostal catheter provides a continuous nerve block resulting in a simple, safe procedure that can ameliorate the pain and splinting associated with multiple rib fractures. Although we experienced no complications, additional investigation is clearly needed.

Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia

Twenty patients undergoing elective thoracotomy were randomized into two groups, receiving either lumbar epidural morphine (n = 10) or continuous extrapleural intercostal nerve block (n = 10). Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function (peak expiratory flow rate, forced expiratory volume in 1 second, and forced vital capacity) was measured on the day before operation and daily for 4 days after operation. Pulse oximetry monitoring was used to determine the incidence of hypoxemia. No significant difference was observed between the groups concerning pain relief (except at 28 hours, in favor of the intercostal nerve block group), respiratory performance, or arterial oxygen saturation. Vomiting, pruritus, and urinary retention occurred only in the epidural group, whereas nausea occurred significantly less frequently in the extrapleural group. We conclude that after thoracotomy continuous extrapleural intercostal nerve block is as effective as lumbar epidural morphine in reducing postoperative pain and restoring pulmonary mechanics. Because of the significantly lower complication rates we favor continuous extrapleural intercostal nerve block for postthoracotomy analgesia.

Site of Action of Continuous Extrapleural Intercostal Nerve Block

Continuous extrapleural intercostal nerve block has been shown in a randomized, controlled study to be effective in reducing postoperative pain after thoracotomy and in restoring pulmonary mechanics. To assess the extent of spread of bupivacaine infused through an extrapleurally placed cannula inserted at thoracotomy, iohexol (Omnipaque) was infused at 5 days postoperatively in 5 patients and computed tomography performed. The contrast medium was confined to the paravertebral space covering on average six intercostal spaces. This study demonstrated that anatomically, the site of action of the bupivacaine infused through an extrapleural cannula was primarily in the paravertebral space.

Continuous Intercostal Nerve Block for Postoperative Analgesia After Surgical Treatment of the Upper

Continuous Intercostal Nerve Block for Postoperative Analgesia After Surgical Treatment of the Upper

Technique du bloc continu des nerfs au niveau du poignet

Functional treatment without pain is a condition for good results after operations at gliding structures (tendons) or periarticular structures. Good analgesia of the arm and hand is obtained with continuous axillary nerve blocks. Often there is concomitant paralysis and active motion is not possible. We therefore use continuous nerve blocks at the wrist. The technique of these blocks is described in the paper. We use a prefabricated catheter set to introduce the polyethylene catheter and to place it near the nerve as in single shot wrist block. This technique for continuous analgesia of the hand can be used for functional treatment after tenolyses, arthrolyses and stable osteosyntheses of fingers. Median, radial and ulnar nerves can be blocked all at the same time or alone.

Analgesic and pulmonary effects of continuous intercostal nerve block following thoracotomy

This study examined the beneficial effects and potential systemic toxicity from continuous intercostal nerve block by repeated bolus injections of bupivacaine. In this double-blind, randomized study, 20 post-thoracotomy patients were assigned to receive four doses of either: 20 ml 0.5% bupivacaine with epinephrine 5 micrograms.ml-1 (bupivacaine group, n = 10), or 20 ml preservative-free saline (placebo group, n = 10) through two indwelling intercostal catheters every six hours. Patients receiving intercostal bupivacaine injections had greater decreases in visual analogue pain scores (VAS) (P less than 0.05) and lower 24 hr morphine requirements, 16.6 +/- 4.6 mg vs 35.8 +/- 7.2 mg, than patients in the placebo group (P less than 0.05). Higher post-injection values of forced expiratory volume in one second, forced vital capacity and peaked expiratory flow rate were also observed in the bupivacaine group (P less than 0.01). Repeated intercostal bupivacaine administration did lead to systemic accumulation, but the peak bupivacaine level after 400 mg was low at 1.2 +/- 0.2 microgram.ml-1. Thus, the technique of continuous intercostal nerve block described in this study is an effective treatment for the control of post-thoracotomy pain.

Reversed-phase and chiral high-performance liquid chromatographic assay of bupivacaine and its enantiomers in clinical samples after continuous extraplural infusion

A previously unreported coupled achiral—chiral high-performance liquid chromatographic method has been developed to assay the levels of bupivacaine and its enantiomers in plasma samples, after the local anaesthetic had been given as a continuous extrapleural intercostal nerve block for 4 days, to relieve postoperative pain following thoracotomy. The method has been used to determine maximum, individual enantiomer and steady state levels in conjunction with an assessment of whether accumulation of bupivacaine occurs. An off-line extraction sample preparation is involved before determination of the “total” levels and final sample clean-up on a cyanopropyl silica column prior to “heart cutting” of the bupivacaine peak to a Chiral-AGP column for assay of the enantiomeric ratio. For an initial 5 patient number the mean maximum level was 5.43 μg/ml against a reported toxic level of around 5 μg/ml, which was reached in 72 h and the S-enantiomer gave slightly increased concentrations over the R-enantiomer for which there is some evidence of higher toxicity.

Site of action of continuous extrapleural intercostal nerve block

Continuous extrapleural intercostal nerve block has been shown in a randomized, controlled study to be effective in reducing postoperative pain after thoracotomy and in restoring pulmonary mechanics. To assess the extent of spread of bupivacaine infused through an extrapleurally placed cannula inserted at thoracotomy, iohexol (Omnipaque) was infused at 5 days postoperatively in 5 patients and computed tomography performed. The contrast medium was confined to the paravertebral space covering on average six intercostal spaces. This study demonstrated that anatomically, the site of action of the bupivacaine infused through an extrapleural cannula was primarily in the paravertebral space.

Continuous extrapleural intercostal nerve block after pleurectomy.

A randomised, double blind trial was carried out in 16 patients undergoing pleurectomy to assess the effect of continuous extrapleural intercostal block on postoperative pain and pulmonary function. Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function was measured on the day before operation and daily for five days after surgery. Eight patients received bupivacaine and eight placebo (saline). The mean pain scores at 4, 8, 16, and 24 hours were 13.3, 8.5, 6.1, and 10 mm respectively in the bupivacaine group compared with 56.3, 41, 46.7, and 35 in the control group; in addition, the bupivacaine group required less papaveretum. Twenty four hours after surgery mean values of peak expiratory flow, forced expiratory volume in one second, and forced vital capacity were reduced to 82%, 76%, and 76% of preoperative control values in the bupivacaine group, and to 39%, 32%, and 36% in the control group. The speed of recovery of pulmonary function was superior in the bupivacaine group. There were no complications related to the infusion. Continuous extrapleural intercostal nerve blockade with bupivacaine provides safe and effective postoperative analgesia and improves respiratory mechanics after pleurectomy.

Efficacy of Continuous Extrapleural Intercostal Nerve Block on Post-Thoracotomy pain and Pulmonary Mechanics

To assess the efficacy of continuous extrapleural intercostal nerve block on postoperative pain and pulmonary function, a prospective, randomized, double-blind, placebo-controlled trial was conducted on 56 patients undergoing elective thoracotomy. Infusion was started before closing the chest and was continued for 5 days. Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function was measured on the day before operation and daily for 5 days. There were 29 patients in a group which received bupivacaine and 27 in a control group which received saline. The bupivacaine group had lower pain scores (P less than 0.01) and required less papaveretum (P less than 0.01) than the control group. Forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate were maximally reduced at 24 h to median values of 56, 60 and 57 per cent, respectively, of preoperative control values in the bupivacaine group, and to 25, 30 and 32 per cent in the control group. These differences are highly significant (P less than 0.01). Restoration of pulmonary function was superior in the bupivacaine group (P less than 0.01). There were no infusion-related complications. After thoracotomy, continuous intercostal blockade with bupivacaine is a safe and effective method of pain relief which reduces the early loss of postoperative pulmonary function significantly and more rapidly restores respiratory mechanics.

Continuous suprascapular nerve block for analgesia of scapular fracture

Fracture of the scapular is uncommon but painful. A case is described in which a comminuted scapular fracture was treated with a continuous suprascapular nerve block. With the patient lying supine an epidural needle was directed towards the scapular notch via a superior approach and an epidural catheter was placed when the notch was believed to have been identified. Repeat injections of 10 ml bupivacaine 0.25 per cent with 1/200,000 epinephrine provided analgesia within minutes and a duration of 8-10 hr. Injection of 10 ml radio-opaque dye demonstrated the catheter to be lateral to the scapular notch. However, dye dispersed throughout the supraspinous fossa including the scapular notch thus blocking the suprascapular nerve. This case demonstrates that continuous suprascapular nerve block can be performed for five days and that location of the scapular notch is less important than previously thought.

Pulmonary complications after lung resection: the effect of continuous extrapleural intercostal nerve block

To assess the efficacy of continuous extrapleural intercostal nerve block (CEINB) with 0.5% bupivacaine on postoperative pain, pulmonary function and pulmonary complications, a prospective, randomised, double blind controlled trial was conducted on comparable patients undergoing lung resections; n = 21 (control), n = 25 (bupivacaine). The bupivacaine group required less papaveretum in the first 24 h (P less than 0.01) and had lower pain scores over 5 postoperative days (P less than 0.01). Pulmonary function recovered earlier in the bupivacaine group. Pulmonary complications occurred in 1 patient with normal lung function and 12 patients with obstructive airways disease (COAD): FEV1/FVC less than 70%. There were no infusion-related complications. CEINB has been shown to be safe and effective in reducing postoperative pain and pulmonary complications. CEINB minimises the loss of lung function after thoracotomy and restores impaired pulmonary mechanics more rapidly.

Continuous Intercostal Nerve Block for Pain Relief after Thoracotomy

Others have demonstrated the effectiveness of intercostal analgesia with bupivacaine hydrochloride (Marcain Plain; Astra). We present a greatly simplified method of effecting this. Our method is dependent on an intact pleura. To date, we have utilized this technique in 81 patients. Seventy-five (92.6%) required no additional analgesic in the first 24 hours following operation and 66 (81.5%), in the subsequent four days. Only 2 patients had postoperative pulmonary complications. No complication related either to the procedure or to the infusion of bupivacaine occurred. The technique as described here is a safe and reliable method of providing analgesia without any side effects after thoracotomy.

Pain Amelioration after Thoracotomy: A Prospective, Randomized Study

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 ± 9.2% (standard deviation; p < 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 ± 7.5% ( p < 0.05) than in the control group (38.4 ± 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.

Effect of Continuous Nerve Block of the Uterus on Stretch-Induced Uterine Activity in the Mid-Trimester

SummaryThe possible roles of endogenous oxytocin, and spinal reflex mechanisms of the autonomic nerves were studied after the induction of abortion in the mid-trimester by uterine stretching. A complete epidural and caudal block of the afferent nerves from the uterus was performed before the insertion of laminaria tents or a balloon into the uterus, and this nerve block was maintained throughout the study. Uterine activity showed no significant difference between the nerve block and non-nerve block groups (P = 0 71), but differed significantly with increasing time after stretching (P < 0 001). Plasma oxytocin values did not increase significantly in either the normal or the nerve-blocked patients.

A Technique for Continuous Intercostal Nerve Block Analgesia following Thoracotomy

A Technique for Continuous Intercostal Nerve Block Analgesia following Thoracotomy

Gonadotrophin response to LH-RH in boys with delayed growth and adolescence.

Plasma luteinising hormone (LH) and follicle-stimulating hormone (FSH) concentrations were measured before and after intravenous luteinising hormone-releasing hormone (LH-RH) in 33 boys with growth delay. Eighteen were prepubertal and 15 pubertal. Basal LH and FSH levels were low in both groups with mean increments after LH-RH of 3.2 +/- 0.8 U/l (mean +/- SEM) and 2.6 +/- 0.4 U/l respectively in the prepubertal and 7.4 +/- 0.7 U/l and 2.0 +/- 0.3 U/l in the pubertal boys. The LH increment showed a positive correlation with increasing bone age (r = 0.71, P less than 0.001); FSH did not. The LH-RH response thus appeared normal in relation to the stage of maturity.