Continuous Regional Anesthesia Research Articles

Continuous regional anesthesia with erector spinae plane catheters for patients with multiple rib fractures.

Opioids are commonly used for acute pain management in patients with rib fractures, but their use poses known risks of addiction and respiratory depression. Regional anesthesia, namely the erector spinae plane(ESP) block, has shown promise as an alternative to opioids in case series. Our aim was to evaluate the efficacy and safety of continuous ropivacaine infusion ESP catheters performed by emergency physicians (EP) for patients with multiple unilateral rib fractures. This retrospective case control study identified polytrauma patients with rib fractures in a 1-year period between 2019 and 2020 who had an ESP catheter placed by EP. The control group consisted of polytrauma patients who did not receive regional anesthesia and were matched by number of rib fractures and age. Our primary outcome was opioid use in morphine milligram equivalents per day (MMED). We compared MMED before and after catheter placement in the treatment group and overall MMED between the control and catheter group. Secondary outcomes included length of hospitalization, rate of intubation, and complications. Subgroup analysis of the same variables was performed on the group of patients whose only injury was rib fractures. The catheter group included 89 patients, matched with an equal number in the control group. Opioid use decreased from 89 to 67 MMED after catheter placement in the treatment group (P=0.003). Overall opioid use during hospitalization did not significantly differ between treatment and control groups (P=0.57). There was a trend toward fewer days of mechanical ventilation and shorter hospital length of stay in the catheter group in patients with isolated rib fractures, but neither of these trends reached statistical significance. Opioid use decreased after ESP catheter implementation and there were no meaningful complications. Although there was no significant difference in opioid use between groups, ESP catheter placement and continuous regional anesthesia by EP is a safe, reasonable adjunct to treat pain from rib fractures.

Optimizing peripheral regional anaesthesia: strategies for single shot and continuous blocks.

Regional anaesthesia is increasingly prominent within anaesthesia, offering alternative analgesic options amidst concerns over opioid-based analgesia. Since Halsted's initial description, the field has burgeoned, with ultrasound visualization revolutionizing local anaesthetic spread assessment, leading to the development of numerous novel techniques. The benefits of regional anaesthesia have gained increasing evidence to support their application, leading to changes within training curricula. Consequently, regional anaesthesia is at a defining moment, embracing the development of core skills for the general anaesthesiologist, whilst also continuing the advancement of the specialty. Recent priority setting projects have focussed attention on key aspects of regional anaesthesia delivery, including pain management, conduct and efficacy, education, and technological innovation. Developments in our current understanding of anatomy and pharmacology, combined with strategies for optimizing the conduct and maximizing efficacy of techniques, minimizing complications, and enhancing outcomes are explored. In addition, advancements in education and training methodologies and the integration of progress in novel technologies will be reviewed. This review highlights recent scientific advances in optimizing both single-shot and continuous peripheral regional anaesthesia techniques. By synthesizing these developments, this review offers valuable insights into the evolving landscape of regional anaesthesia, aiming to improve clinical practice and patient care.

Impact of self-coiling catheters for continuous popliteal sciatic block on postoperative pain level and dislocation rate: a randomized controlled trial

BackgroundDislocation of catheters within the tissue is a challenge in continuous regional anesthesia. A novel self-coiling catheter design is available and has demonstrated a lower dislocation rate in a cadaver model. The dislocation rate and effect on postoperative pain of these catheters in vivo has yet to be determined and were the subjects of this investigation.MethodsAfter ethics committee approval 140 patients undergoing elective distal lower limb surgery were enrolled in this prospective randomized controlled trial. Preoperatively, patients were randomly assigned and received either the conventional (n = 70) or self-coiling catheter (n = 70) for ultrasound-guided popliteal sciatic nerve block in short axis view and by the in-plane approach from lateral to medial. The primary outcome was pain intensity after surgery and on the following three postoperative days. Secondary outcomes investigated were dislocation rate in situ determined by sonography, catheter movement visible from outside, opioid consumption as well as leakage at the puncture site.ResultsAll catheters were successfully inserted. The study population of self-coiling catheters had significantly lower mean numeric rating scale values than the reference cohort on the first (p = 0.01) and second postoperative days (p < 0.01). Sonographic evaluation demonstrated, 42 standard catheters (60%) and 10 self-coiling catheters (14.3%) were dislocated in situ within the first three postoperative days. The externally visible movement of the catheters at insertion site did not differ significantly between groups through the third postoperative day. The opioid consumption was significantly lower in the self-coiling catheter group on the day of surgery and on the second and third postoperative days (p = 0.04, p = 0.03 and p = 0.04, respectively).ConclusionThe self-coiling catheter offers a better postoperative pain control and a lower dislocation rate within the tissue when blocking the popliteal sciatic nerve compared to a conventional catheter. Further trials in large patient cohorts are warranted to investigate the potential beneficial effects of self-coiling catheters for other localisations and other application techniques.Trial registrationThe trial was registered at German Clinical Trials Register (DRKS) on 08/04/2020 (DRKS00020938, retrospectively registered).

A not so sweet scenario: impact of perioperative glucose control on regional anesthetic techniques for orthopedic surgery.

Diabetes and hyperglycemia are well established risk factors for complications associated with common orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this modality in a safe manner for patients with diabetes and even some with preexisting, localized infections. Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a selective approach to nerve catheter placement in this population and even some who already have localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients have improved pain control and an exceedingly low rate of complications associated with nerve catheter use. Based on our experience and reading of the literature, we advocate for a liberalized approach to use of continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus guidelines tailored to institutions' resources and monitoring capabilities can be a useful tool for standardizing care. It may also increase access to the clinical benefits of this modality in a population particularly vulnerable to opioid related adverse effects.

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis.

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the grading ofrecommendations, assessment, development, and evaluation system. Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. PROSPERO (CRD42021238916); registered 25 February 2021.

Effectiveness and Safety of Continuous Infusion Regional Anesthesia Pumps for Pain After Thoracopelvic Fusion Surgery for Persistent Spinal Pain Syndrome

Postoperative pain after complex revision spine surgery, especially for the treatment of persistent spinal pain syndrome (PSPS), is frequently severe and can be debilitating, requiring the use of intravenous and oral opioids. To the best of our knowledge, the present study is the first to evaluate the effectiveness and safety of a continuous infusion regional anesthesia pump placed after thoracopelvic fusion for the treatment of PSPS. We performed a retrospective comparative study of consecutive patients who had undergone thoracopelvic fusion for PSPS. The patients included in the present study had either had a continuous infusion regional anesthesia pump placed during surgery or had not (control). Demographics, use of preoperative and postoperative opioids, postoperative adverse events, length of hospital stay, and 90-day readmission were recorded. The patients in the pump group (n= 14) had used fewer opioids during their hospital stay compared with the control group (n= 12; P= 0.6). This difference was greater for postoperative days 1 and 2 (P= 0.3 and P= 0.2, respectively). No significant difference was found in opioid usage during the first 14 days after surgery (P= 0.8) or at the 3-month postoperative follow-up evaluation (P= 0.8). Furthermore, no significant difference was found between the 2 groups in terms of postoperative complications. The pump group had a 1.4-day shorter hospital stay (P= 0.7). The control group had more 90-day readmissions than did the pump group (P= 0.2). Despite showing a trend toward less usage of opioids during the first 2 days after surgery and a shorter hospital stay with no increased complications in the pump group, the study data failed to demonstrate a statistically significant difference between the two groups.

6: Nerve Blocks With Targeted Muscle Reinnervation Reduce Acute Postoperative Opioid Use in Major Lower Extremity Amputation

Purpose:Major amputations of the lower extremity, specifically through and below the knee, are morbid procedures requiring general anesthesia typically followed by high doses of postoperative opioids. Many are performed on highly comorbid, chronic wound patients with a potential for increased opioid use following surgery. Given the current opioid epidemic, perioperative narcotic-reduction strategies are paramount. Our center instituted a protocol for major amputations that includes continuous regional anesthesia, for intraoperative and postoperative pain control, and targeted muscle reinnervation (TMR) nerve transfers to mitigate long-term pain. The aim of this study was to analyze the impact of continuous regional anesthesia and TMR on early postoperative opioid requirements after major lower extremity amputation at our limb salvage center.Methods:We retrospectively reviewed our center’s below-knee and through-knee-amputations from 2017-2019 for utilization of regional pain catheters and TMR nerve transfers. Opioid usage as morphine milligram equivalents (MMEs) was tracked for the first seven postoperative days. Baseline opioid dose was defined by the documented opioid use one day before amputation. Patients were categorized into one of four groups, based on whether regional pain catheter and/or TMR were used. Kruskal-Wallis testing was used to assess baseline opioid use between groups. Bivariate linear regression was used to assess postoperative opioid use of each group compared to the control group. Logistic regression analysis was conducted to examine association between TMR and changes in opioid use postoperatively versus baseline.Results:198 patients were reviewed. 95 patients received perioperative regional anesthesia, of which 81 underwent TMR. 103 patients did not receive regional anesthesia, of which 30 underwent TMR. Average baseline opioid use was 40.6 MME in patients treated with TMR and regional anesthesia, 60.2 MME with TMR and without regional anesthesia, 28.7 MME without TMR and with regional anesthesia, and 132.6 MME without TMR and regional anesthesia (p=0.0004). Multivariate analysis showed that undergoing TMR, without regional anesthesia, significantly decreased postoperative opioid use by 111.7 MME, compared to the control group (p=0.006). Use of regional anesthesia, with TMR, provided an additive effect, significantly decreasing postoperative opioid use by 124.3 MME, compared to control (p<0.0001). Interestingly, regional anesthesia without TMR decreased postoperative opioid use by 93.4 MME, but without significance (p=0.08). Odds of decreased opioid use postoperatively compared to baseline was 1.91 times higher with TMR than without TMR (p=0.04).Conclusion:TMR nerve transfers were found to be independently effective at reducing postoperative opioid requirements after major lower extremity amputation. Concurrent use of regional anesthesia compounded this effect. Minimizing baseline opioid use prior to amputation may decrease opioid use postoperatively. TMR nerve transfer with continuous regional anesthesia protocol can decrease reliance on postoperative pain control with opioids in lower extremity major amputation patients.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients

BackgroundFascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. MethodsWe performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. Results107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. ConclusionsWe report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Painful myokymia after surgery in a patient with Isaacs\u2019 syndrome: a case report

BackgroundIsaacs’ syndrome is a peripheral nerve hyperexcitability syndrome and rare acquired channel disease. The symptoms (myokymia, neuromyotonia, and muscle spasm) emerge even during sleep. This report describes the anesthetic management, especially neuromuscular blocking drugs and postoperative pain, in a case of Isaacs’ syndrome.Case presentationA 63-year-old woman with Isaacs’ syndrome underwent elective laparoscopic distal gastrectomy under general anesthesia without epidural anesthesia. She received double filtration plasmapheresis four times to alleviate symptoms before surgery. To avoid a prolonged neuromuscular blockade, we performed total intravenous anesthesia and titrated muscle relaxant with neuromuscular monitoring. Anesthetic management was performed without any problems. However, pain management after surgery proved difficult as she experienced severe pain due to myokymia.ConclusionsDespite attempts to minimize symptoms, severe postoperative pain associated with myokymia occurred. Continuous regional anesthesia should be considered to treat pain from abnormal discharge in the central nervous system in Isaacs’ syndrome.

Epidural Anesthesia to Effectively Manage Pain and Facilitate Rehabilitation in a Pediatric Case of Complex Regional Pain Syndrome

There is a paucity of information related to treatment of pediatric CRPS. Treatment of CRPS in pediatric patients has been guided by adult recommendations, which consist of a multidisciplinary approach involving pharmacotherapy, physical therapy, and psychotherapy, as appropriate. Patients unable to tolerate physical therapy with traditional oral pharmacotherapy may require more invasive pain management techniques such as sympathetic blocks, epidural infusion of analgesics, or spinal cord stimulation to facilitate restoration of function. This case report describes the successful use of epidural infusion of fentanyl, clonidine, and bupivacaine through a tunneled epidural lumbar catheter for pain management in an 11-year-old girl who developed complex regional pain syndrome I (CRPS I) approximately 2 months after sustaining an injury to her right knee. Following short-lasting pain relief from 3 repeated blocks, she underwent an implant of a tunneled epidural catheter (TEC) and a 4-week infusion of fentanyl (2 mcg/mL), clonidine (1 mcg/mL), and bupivacaine (0.04%). At last follow-up, approximately 3.5 months after implant of the TEC, the patient’s pain and symptoms were completely resolved, her range of motion and function were completely restored, and her physical activity had returned to pre-injury levels. Key words: Complex regional pain syndrome (CRPS), tunneled epidural catheter, pediatric, continuous regional anesthesia, epidural analgesia, continuous epidural anesthesia, interventional pain management

Prolonged Catheter Use and Infection in Regional Anesthesia: A Retrospective Registry Analysis.

Prolonged catheter use is controversial because of the risk of catheter-related infection, but the extent to which the risk increases over time remains unknown. We thus assessed the time-dependence of catheter-related infection risk up to 15 days. Our analysis was based on the German Network for Regional Anesthesia, which includes 25 centers. We considered 44,555 patients who had surgery between 2007 and 2014 and had continuous regional anesthesia as well as complete covariable details. Cox regression analysis was performed and adjusted for confounding covariables to examine the relationship between catheter duration and probability of infection-free catheter use. After adjustment for confounding factors, the probability of infection-free catheter use decreases with each day of peripheral and epidural catheter use. In peripheral catheters, it was 99% at day 4 of catheter duration, 96% at day 7, and 73% at day 15. In epidural catheters, it was 99% at day 4 of catheter duration, 95% at day 7, and 73% at day 15. Only 31 patients (0.07%) had severe infections that prompted surgical intervention. Among these were five catheters that initially had only mild or moderate signs of infection and were left in situ; all progressed to severe infections. Infection risk in catheter use increases over time, especially after four days. Infected catheters should be removed as soon as practical. An online visual overview is available for this article at http://links.lww.com/ALN/B683.

Costoclavicular Space: A Reliable Gate for Continuous Regional Anesthesia Catheter Insertion.

Costoclavicular Space: A Reliable Gate for Continuous Regional Anesthesia Catheter Insertion.

Continuous regional anesthesia: a review of perioperative outcome benefits.

Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. Tissue injury is responsible for the inflammatory reaction and physiologic stress response observed during the perioperative period and can influence a patient's recovery trajectory. Regional anesthesia can modulate the inflammatory response through the direct anti-inflammatory effect of local anesthetics, blocking neural afferents, and blunting sympathetic activation. Moreover, continuous techniques (e.g., epidural and perineural catheters) that provide longer duration and titratable pain relief in the perioperative period may be protective against the development of persistent post-surgical pain by providing effective acute pain management and decreasing exposure to opioids. To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.

Continuous Regional Anesthesia and Inpatient Rehabilitation for Pediatric Complex Regional Pain Syndrome.

Evidence supports treatment of pediatric complex regional pain syndromes (CRPS) with physical and occupational therapy and cognitive-behavioral therapy. Some patients have persistent pain and/or limb dysfunction despite these treatments. We performed a retrospective study of pediatric patients with CRPS treated by continuous epidural or peripheral perineural local anesthetic infusions along with inpatient rehabilitation at Boston Children's Hospital. After approval from the institutional review board, electronic medical records were reviewed for patients treated between September 2003 and September 2014. Primary outcomes were pain and functional scores. Data were collected at the first encounter, at follow-up visits between 4 months before and after admission, and daily while inpatient. Changes over time were assessed using Wilcoxon tests with Dunn corrections. Clinical significance of benefit or harm was assessed by the method of Jacobson and Truax. Response predictors were analyzed using linear mixed models and exploratory logarithmic regression analyses. Pain, function, and disability scores improved during hospitalization and in follow-up over a 4-month period. Seventy percent of patients achieved clinically significant benefit (56% for pain reduction and 40% increased functionality, respectively). Univariate and adjusted predictors of favorable outcome included preadmission resting Numeric Pain Rating Scale score of less than 6 (odds ratio, 5.0; P = 0.0164 and subsequent attendance at the Pediatric Pain Rehabilitation Center at Boston Children's Hospital (odds ratio, 5.0; P = 0.0206). Mean pain scores greater than 3 during the regional anesthesia infusion predicted less favorable outcome. Continuous regional anesthesia may be an option to facilitate intensive rehabilitation for selected pediatric patients with CRPS. Further research should help clarify the role of regional anesthesia in a comprehensive management program.

Single-dose Antibiotic Prophylaxis in Regional Anesthesia: A Retrospective Registry Analysis.

Catheter-related infection is a serious complication of continuous regional anesthesia. The authors tested the hypothesis that single-dose antibiotic prophylaxis is associated with a lower incidence of catheter-related infections. Our analysis was based on cases in the 25-center German Network for Regional Anesthesia database recorded between 2007 and 2014. Forty thousand three hundred sixty-two surgical patients who had continuous regional anesthesia were grouped into no antibiotic prophylaxis (n = 15,965) and single-dose antibiotic prophylaxis (n = 24,397). Catheter-related infections in each group were compared with chi-square test after 1:1 propensity-score matching. Odds ratios (ORs [95% CI]) were calculated with logistic regression and adjusted for imbalanced variables (standardized difference more than 0.1). Propensity matching successfully paired 11,307 patients with single-dose antibiotic prophylaxis (46% of 24,397 patients) and with 11,307 controls (71% of 15,965 patients). For peripheral catheters, the incidence without antibiotics (2.4%) was greater than with antibiotic prophylaxis (1.1%, P < 0.001; adjusted OR, 2.02; 95% CI, 1.49 to 2.75, P < 0.001). Infections of epidural catheters were also more common without antibiotics (5.2%) than with antibiotics (3.1%, P < 0.001; adjusted OR, 1.94; 95% CI, 1.55 to 2.43, P < 0.001). Single-dose antibiotic prophylaxis was associated with fewer peripheral and epidural catheter infections.

Continuous Thoracic Epidural Anesthesia for Mammoplasty Reduction

Female 45 years old patient with bilateral breast hyperplasia. A functional reduction mammoplasty is done under continuous high thoracic epidural regional anesthesia (0.5% bupivacaine) through an epidural catheter inserted in T3-T4 for 7 hours. The patient presented a permanent hemodynamic stability without deterioration in ventilatory parameters. She did not have neurological injuries. Excellent continuous epidural analgesia (0.125% Bupivacaine) in immediate post-operative reaction and within the next 24 hours. The continuous high thoracic epidural anesthesia is an alternative anesthetic technique in breast surgery.

Lidocaine versus ropivacaine for postoperative continuous paravertebral nerve blocks in patients undergoing laparoscopic bowel surgery: a randomized, controlled, double-blinded, pilot study.

Background and objectivesLidocaine could provide many advantages in continuous regional anesthesia techniques, including faster onset, greater titratability, and lower cost than long-acting local anesthetics. This prospective, randomized, double-blinded, pilot study is therefore intended to compare lidocaine to ropivacaine in bilateral continuous paravertebral blocks using a multimodal approach for postoperative pain management following laparoscopic bowel surgery.MethodsThirty-five ASA I–III consecutive patients undergoing elective laparoscopic bowel surgery and bilateral thoracic paravertebral continuous blocks were analyzed: bilateral thoracic paravertebral infusions of ropivacaine 0.2% (Group Ropi, n=18) or lidocaine 0.25% (Group Lido, n=17) were started at 7 mL/h in the postanesthesia care unit. For each patient, we collected numerical rating scores (NRS) for pain at rest and during movement at baseline, at postanesthesia care unit discharge, at 24 hours and 48 hours after the end of surgery, as well as hydromorphone patient-controlled analgesia requirements, local anesthetic consumption, side effects, postoperative complications, and functional outcomes.ResultsNo effect of group distribution on NRS scores for pain at rest or at movement (P=0.823 and P=0.146), nor on hydromorphone (P=0.635) or local anesthetic consumption (P=0.063) was demonstrated at any analyzed time point. Hospital length of stay and spontaneous ambulation were comparable between groups (P=0.636 and P=0.148). In the context of a multimodal approach, the two drugs showed comparable safety profiles.DiscussionLidocaine 0.25% and ropivacaine 0.2% provided similar analgesic profiles after elective abdominal surgeries, without any difference in terms of functional outcomes. The easier titratability of lidocaine together with its lower cost induced our clinical practice to definitely switch from ropivacaine to lidocaine for postoperative bilateral paravertebral continuous infusions.

Separation of stimulating catheters for continuous peripheral regional anesthesia during their removal - two case reports and a critical appraisal of the use of steel-coil containing stimulating catheters.

PurposeStimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia. The incidence of reported complications is somewhat similar to that for non-stimulating catheters. However, as many stimulating catheters contain a coiled steel wire for optimal stimulation, they may cause specific complications.Clinical featuresIn this report, we present two cases of complicated removals of stimulating catheters. During both removals, a part of the metal wire was left “decoiled” next to the supraclavicular and interscalene plexus, respectively. The strategies used to determine steel wire localization and a description of the successful removal of these steel wires are included in this report.ConclusionCatheter separation and problems with residual metal wire components of stimulating catheters seem to be a rare but specific problem during removal. Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer’s instructions, and take care during catheter removal. Manufacturers should focus on technical solutions to avoid rare but relevant complications such as catheter tip decoiling and separation of stimulating catheters during removal.

Regional anaesthesia in patients with lower limb injury

Almost all surgical procedures following injury can be provided in peripheral regional anaesthesia or spinal anaesthesia - under consideration of specific contraindications. The majority of injuries at the lower limb are associated with severe pain and immobilization during the postoperative phase. Moreover, opioids are often required which are related to nausea, vomiting and impairment of vigilance. For avoidance of those side effects, regional anaesthesia techniques should be considered as a more effective approach with a better profile of side effects. Hip and proximal femur fractures are more frequent in elder patients with a corresponding high morbidity. Therefore anaesthesia is challenging in those patients. Even injuries of the long bones - like the femur and the tibia - are causing severe pain, therefore an appropriate concept for acute pain therapy is required. Moreover, for injuries with affection of bony joint-structures (i. e. knee, ankle, calcaneus) and marked soft-tissue injuries continuous regional anaesthesia techniques could provide advantages during acute pain therapy.

Diabetes: a risk factor for catheter-associated infections.

The incidence of infectious complications associated with continuous regional anesthesia techniques is a matter of concern. Our objective was to determine whether patients suffering from diabetes are at an increased risk of catheter-related infectious complications. The German Network for Regional Anaesthesia database was analyzed between 2007 and 2012. After proof of plausibility, data of 36,881 patients undergoing continuous regional anesthesia were grouped in I: no diabetes (n = 32,891) and II: any diabetes (n = 3990). The analysis focused on catheter-related infections after strict definition. Differences among the groups were tested with t and χ tests. Odds ratios were calculated with logistic regression and adjusted for potential confounders. Patients with a diagnosis of diabetes had an increased incidence of catheter-related infections (no diabetes 3.0% vs any diabetes 4.2%; P < 0.001). Among all patients, diabetes remained an independent risk factor for infections for all sites after the adjustment for potential confounders (odds ratio [OR] = 1.26; 95% confidence interval [95% CI], 1.02-1.55; P = 0.036). The risk of infection was significantly increased in peripheral catheters only in the lower limb (adjusted OR = 2.42; 95% CI, 1.05-5.57; P = 0.039). If neuraxial catheters were used, the risk was significantly increased only in lumbar epidural (adjusted OR = 2.09; 95% CI, 1.18-3.73; P = 0.012) for diabetic patients compared with nondiabetic patients. The presence of diabetes is associated with an increased risk for catheter-related infections in lower limb and lumbar epidural. Specific care should be taken to avoid and detect infections in this population.