Combined Nerve Block Research Articles

COMPARISON OF POSTOPERATIVE PAIN SCORES AND MEDICATION USAGE BETWEEN THREE PAIN CONTROL STRATEGIES FOR PEDIATRIC ANTERIOR CRUCIATE LIGAMENT (ACL) SURGERY

Background: Assessment and management of postoperative pain in the pediatric population after ACL surgery can be challenging, and the optimal approach to pain control remains controversial. Recent studies have shown that the use of intraoperative nerve blocks may reduce the need for opioids to control pain in the immediate postoperative period. However, it is not clear which block type is the most beneficial for the pediatric outpatient setting. The objective of our study was to compare effectiveness of pain control between three different pain management strategies in the pediatric ACL population. Methods: A retrospective chart review from 2013-2017 of patients ages 12-17 receiving an elective ACL reconstruction. Three types of analgesia were included: femoral nerve block, combined femoral + sciatic block, and intraarticular injection of bupivacaine with cold therapy in the Post Anesthesia Care Unit (PACU) (each used by three different surgeons as their standard preference in three different hospitals), n = 50 per group. The primary variable was postoperative pain scores (visual analog scale 1-10) in the PACU. Secondary variables collected were demographic data, graft type, time in PACU and intraoperative/postoperative opioid use. Results: The mean (+ SD) age of the cohort was 15.3 + 1.4 years; there were no differences in age, BMI or ratio of boys and girls between the 3 groups (n=50 per group). However, the femoral nerve block group had a significantly lower percentage of Caucasians (28%, P = 0.002) compared to the group with combined blocks (58%) and intraarticular injection (56%). Less than 50% of patients in the combined nerve block group had opioids intraoperatively or in the PACU compared to nearly 100% of patients in the other two groups (P < 0.0001). Also, for patients receiving opioids, the total intraoperative morphine equivalents and PACU pain scores (all patients) were significantly less in the combined block group (P < 0.001). For patients receiving opioids in the PACU, the total morphine equivalents was significantly higher in the intraarticular injection group compared to the nerve block groups (P < 0.0001). Total time in the PACU was 25% longer for patients in the combined block group (P < 0.0001). Conclusion: Patients in the combined femoral and sciatic nerve block group had significantly better pain scores in the PACU with less cumulative morphine equivalent consumption compared to the femoral nerve block group and the intraarticular injection group.

Clinical effects of single femoral nerve block in combination with general anesthesia on geriatric patients receiving total knee arthroplasty.

Objective:To evaluate the clinical effects of single femoral nerve block (sFNB) combined with general anesthesia on geriatric patients receiving unilateral total knee arthroplasty (UTKA).Methods:Sixty geriatric UTKA patients who were treated in The First People's Hospital of Changzhou from January 2015 to August 2015 were randomly divided into an sFNB + laryngeal mask airway (FLA) group, an sFNB + tracheal intubation (FGA) group and a tracheal intubation (GA) group. Their clinical parameters and indices were recorded. They were scored by the Visual Analogue Scale (VAS).Results:All patients completed this study. FLA and FGA groups used less propofol, remifentanil and fentanyl than GA group (P<0.01), with shorter recovery time and extubation time (P<0.05). Compared to GA group, FLA and FGA groups had lower systolic blood pressures at T3, T4 and T5 (P<0.05), and lower heart rates at T5 (P<0.05). FLA and FGA groups had fewer cases of adverse reactions after extubation (P<0.01). FLA group was less prone to irritating cough after extubation and pharyngeal pain than FGA and GA groups (P<0.01). The postoperative six hour and 24 hour VAS scores in resting state as well as the postoperative 24 hour and 48 hour scores in training state of FLA and FGA groups were lower than those of GA group (P<0.05). FLA and FGA groups used significantly lower times and total doses of patient-controlled intravenous analgesia pump.Conclusion:sFNB combined with general anesthesia, especially that using laryngeal mask, were superior to general anesthesia alone, which reduced recovery and extubation times, and decreased intraoperative and postoperative drug uses, postoperative early VAS score and adverse reactions.

Ultrasound-guided lower extremity nerve block to facilitate the closed reduction of a dislocated hip prosthesisin Geriatric Patient

Hip dislocation constitutes an orthopaedic emergency.Prosthetic hip dislocation is an unfortunate complication for patients whohave previously undergone total hip arthroplasty.A 75-year-old female was scheduled for the closed reduction of hipdislocation which occurred 12hours ago by the accident. We performed combined nerve blocks (femoral, lateral femoralcutaneous) with 20 ml of 0.25% ropivacaine with intravenous sedation for the closed reduction of righthip joint. The procedurewas performed uneventfully and the patient was kept stable hemodynamically.

Effects of a combined nerve block on intraoperative stress and postoperative immune function in elderly patients subjected to total hip replacement: study protocol for a randomized controlled trial

Background: Anesthesia, surgery, and other nociceptive stimuli affect stress and hemorheological indices, impact physiological function, decrease immune function, and thereby influence recovery of hip joint function in elderly patients who undergo total hip replacement. Previous anesthesia methods for hip replacement in elderly patients include general, lumbar puncture, or epidural anesthesia alone. A combined nerve block is more suitable for total hip replacement in the elderly because of the safety and reliability of the method. In this study, we hypothesized that a combined nerve block is superior to any previous anesthesia method alone for total hip replacement in the elderly. Specifically, we hypothesized that intraoperative stress, hemorheological indices, postoperative immune function, and incidence of postoperative complications would be more favorable using a combined nerve block compared with previous anesthesia methods. Methods/Design: This is a prospective, single-center, randomized controlled, open-label trial, which will be performed at Qinghai University Affiliated Hospital, China. A total of 120 elderly patients scheduled to undergo total hip replacement will be randomly assigned to undergo a combined nerve block (involving lower lumbar plexus, sciatic nerve, and paraspinal nerve L 1-2 ) (experimental group, n = 60), or general anesthesia (control group, n = 60). All patients will be followed up at 3 months. The primary outcome is serum cortisol concentration during surgery, as a measure of intraoperative stress. Secondary outcomes include serum cortisol concentration prior to anesthesia, and prior to and immediately after surgery; blood glucose level prior to anesthesia, and prior to, during, and after surgery, used to evaluate stress during different times. In addition, immune function-related indices including absolute leukocyte count, absolute neutrophil count, interleukin-1, interleukin-6, tumor necrosis factor-α, and T-lymphocyte subset levels prior to anesthesia, immediately after surgery, 1, 3, 7 days, and 3 months after surgery, will be used to evaluate patients' immune function after surgery. Hemorheological indices including electrocardiogram, pulse, systolic pressure, diastolic pressure, heart rate, blood gas analysis prior to anesthesia, and during and after surgery will be used to investigate changes in blood-related indices. Lastly, incidence of adverse events 1, 3, 7 days, and 3 months after surgery will be used to evaluate postoperative complications. Discussion: This study will investigate the effects of a combined nerve block versus general anesthesia on intraoperative stress and postoperative immune function in elderly patients who undergo total hip replacement. This study will provide objective evidence for selection of anesthesia method for total hip replacement in the elderly, with the aim of reducing intraoperative risks and postoperative complications. Trial registration: ClinicalTrial.gov identifier: NCT02884388; registered on 19 August 2016. Ethics: This trial has been approved by Ethics Committee, Qinghai University Affiliated Hospital, China (approval number QHY1017D) and will be performed in accordance with the Declaration of Helsinki, formulated by the World Medical Association. Informed consent: Signed informed consent will be obtained from the patients or their relatives.

Penile nerve block at the base of penis in combination with intravenous ketamin plus midazolam versus general anaesthesia(GA) in children undergoing circumcision for post operative pain management in the Eastern Nepal

Adequate post operative analgesia in children provides satisfactory psychological objective of this study was to compare the post operative analgesia requirement and child satisfaction between two groups, general anaesthesia(GA) alone and GA in combination with penile nerve block. This prospective randomized study was conducted in 50 children aged 6 to 14 years, who underwent circumcision. The boys were randomly allocated into two groups. Group A (n = 25) received GA with Single shot ketamin 2mg/kg IV plus midazolam 0.1 mg/kg and dorsal penile nerve block at the base of penis prior to circumcision with and Group B (n = 25) received GA with ketamine 2mg/kg IV plus midazolam 0.1 mg/kg plus halothane by laryngeal mask. Severity of pain was assessed quantitatively by children’s hospital eastern Ontario pain scale (CHEOPS). The pain intensity was assessed at one hour A1 in group A and B1 for group B and at two hour A2 for group A and B2 for group B during postoperatively period for two hours. Statistical analysis was done by SPSS method. The post operative analgesia was satisfactory with CHEOPS score 6 or &lt;6 in group A 1. In group A 2 twenty two out of twenty five cases had CHEOPS score &lt;6.Where as in group B1 and B2 it was &gt; 6 .Which was statistically 100% significant. In conclu­sion, combined penile nerve block in combination with intravenous ketamine plus midazolam is the satisfactory method of Post operative pain management in children undergoing circumcision. DOI: http://dx.doi.org/10.3126/jcmc.v4i1.10846 Journal of Chitwan Medical College 2014; 4(1): 33-36

Dexmedetomidine and propofol infusion on sedation characteristics in patients undergoing sciatic nerve block in combination with femoral nerve block via anterior approach

ObjectiveDexmedetomidine is an α-2 adrenergic agonist having wide range of effects including sedation in mammalian brain, and has analgesic as well as sympatholytic properties. This study aimed to compare the effects of dexmedetomidine and propofol infusion on sedation characteristics in patients undergoing combined sciatic nerve and femoral nerve block via anterior approach for lower limb orthopedic procedure. MethodsForty patients, who were between 18 and 65 years old, this study was made at anesthesiology clinic of Bağcılar training and research hospital in 08 September 2011 to 07 June 2012, and underwent surgical procedure due to fractures lateral and medial malleol, were included. Sciatic nerve and femoral nerve block were conducted with an anterior approach on all patients included in the study, with an ultrasonography. The patients were randomly divided into dexmedetomidine [Group D (n=20); 0.5μgkg−1h−1] and propofol [Group P (n=20); 3mgkg−1h–1] infusion groups. ResultsThe vital findings and intra-operative Ramsay sedation scale values were similar in both groups. Time taken for sedation to start and time required for sedation to become over of Group D were significantly higher than those of Group P (p<0.001 for each). ConclusionsSubstitution of dexmedetomidine instead of propofol prolongs the times to start of sedation, the times to end of sedation and duration of sedation.

Preoperative Sciatic and Femoral Nerve Blocks for Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis

Objective: Uncontrolled postoperative pain and nausea and vomiting are the most common causes for hospital admission following ambulatory anterior cruciate ligament (ACL) reconstruction. Therefore, finding techniques that provide excellent postoperative pain control is of critical importance. This retrospective study compared patients who received preoperative femoral nerve blockade to those who received combined femoral and sciatic nerve blockade. We hypothesized that a combined preoperative nerve block would result in lower postoperative pain, decreased postoperative opioid consumption, and shorter recovery. Methods: The medical records of 191 patients who underwent ACL reconstruction were retrospectively analyzed. We then developed multivariable regression models for each primary outcome parameter. Results: The postoperative pain scores were lower in patients receiving a combined nerve block compared with patients receiving a femoral nerve block (P<0.001) and higher in patients receiving an autograft vs. an allograft (P=0.009). Total morphine equivalents were lower in patients receiving combined nerve block versus patients receiving femoral nerve block (P<0.001) and higher in patients with a higher BMI (P<0.001). Recovery unit length of stay was prolonged by more than 25 minutes in patients with PONV (P=0.001) and in patients who needed a postoperative nerve block in the recovery unit (P ≤ 0.001). Conclusions: A preoperative combined sciatic and femoral nerve block improved postoperative pain management, while postoperative nausea and vomiting or the need for a postoperative nerve block increased the recovery unit time.

Intermittent sciatic block combined with continuous femoral block for patients undergoing knee arthroplasty

Intermittent sciatic block combined with continuous femoral block for patients undergoing knee arthroplasty

Combined Use Of Ultrasound Guided Infraclavicular Block And Lateral Femoral Cutaneous Nerve Block In Upper Extremity Reconstruction Requiring Large Skin Graft: Case Report

Combined nerve blocks of the upper extremity and lower limb in same operation rarely performed due to the risk of systemic toxicity of local anesthetics. Therefore, general anesthesia is generally preferred in this operations. However, use of ultrasound allows reliable deposition of the anesthetic around the nerves, potentially lowering the local anesthetic requirement. In this case report, we present a 44-year-old, ASA physical status I, male patient who was operated for upper extremity reconstruction requiring skin graft from anterolateral thigh region under ultrasound-guided infraclavicular brachial plexus block and lateral femoral cutaneous nerve block. The block was successful and no block-related complications were noted. We think that combining an ultrasound guided infraclavicular brachial plexus block and a lateral femoral cutaneous nerve block is a clinically useful and safe technique and an alternative anesthetic method for procedures requiring skin grafts for the upper extremity.

Efficacy of intravenous parecoxib combined with femoral nerve block for postoperative analgesia and knee functional rehabilitation in elderly patients following total knee replacement

Objective To investigate the efficacy of intravenous parecoxib combined with femoral nerve block on postoperative analgesia and knee functional rehabilitation in elderly patients following total knee replacement.Methods Forty elderly patients with osteoarthritis schedu[ed for total knee arthroplasty under general anesthesia,aged 65-74 years,weighing 45-90 kg,ASA [Ⅱ,were randomly divided into two groups( n ＝ 20 each).FNB group received femoral nerve blockade for postoperative analgesia ( local injection of 0.25 ％ ropivacaine 25 ml at the end of surgery,repeated every 8 h up to 72 h after surgery).FNB-Pa group received the femoral nerve blockade plus the parecoxib (administered Ⅳ bolus of 40 mg 30 min before the end of surgery,12,24,and 48 h after surgery respectively).Pain was scored at rest or during continuous passive motion using Visual Analog Scale (VAS).The Hospital for Special Surgery (HSS) knee score was determinated before surgery,at 24,48 and 72 h after surgery respectively.Side effects were also recorded in both groups.Results VAS score was significantly lower at rest and during continuous passive motion in FNB-Pa group than in FNB group ( P < 0.05).Compared with baseline value,HSS score increased significantly during postoperative analgesia in both groups( P < 0.05 or 0.01 ).HSS score were significantly higher at 48 h and 72 h after surgery in FNB-Pa group than in FNB group ( P < 0.05).No severe related side effects occured in both groups.Conclusion Femoral nerve block in combination with intravenous parecoxib can safely and effectively relieve the static and dynamic pain after total knee replacement and is helpful for rehabilitation of the prosthesis knee joint function after surgery. Key words: Cyclooxygenase inhibitors; Femoral nerve; Nerve block; Arthroplasty,replacement,knee; Pain,postoperative ; Analgesia

Ultrasound Guided Obturator versus Sciatic Nerve Block in Addition to Continuous Femoral Nerve Block for Analgesia after Total Knee Arthroplasty

Both obturator and sciatic nerve block in combination with femoral nerve block (FNB) have been suggested to be useful in relieving pain after total knee arthroplasty (TKA), compared with FNB alone. We compared their efficacy in this retrospective study. For six consecutive months, patients undergoing unilateral TKA under general anesthesia with continuous FNB plus obturator nerve block (n = 8) or continuous FNB plus sciatic nerve block (n = 8) were investigated. Knee pain was assessed using visual analogue scale (VAS) on the day of surgery and on postoperative days one to three. In addition, we also investigated intraoperative and postoperative morphine consumption. VAS scores and total morphine consumption were not different between the two groups, although patients in the FNB plus sciatic nerve block group were administered less morphine during surgery. Sciatic nerve block with continuous FNB may be superior to obturator nerve block with continuous FNB for analgesia during surgery for TKA.

PROSPECTIVE RANDOMIZED STUDY COMPARING TWO ANESTHETIC METHODS FOR SHOULDER SURGERY

Objective: To evaluate the efficacy of suprascapular nerve block in combination with infusion of anesthetic into the subacromial space, compared with interscalene block. Methods: Forty-five patients with small or medium-sized isolated supraspinatus tendon lesions who underwent arthroscopic repair were prospectively and comparatively evaluated through random assignation to three groups of 15, each with a different combination of anesthetic methods. The efficacy of postoperative analgesia was measured using the visual analogue scale for pain and the analgesic, anti-inflammatory and opioid drug consumption. Inhalation anesthetic consumption during surgery was also compared between the groups. Results: The statistical analysis did not find any statistically significant differences among the groups regarding anesthetic consumption during surgery or postoperative analgesic efficacy during the first 48 hours. Conclusion: Suprascapular nerve block with infusion of anesthetic into the subacromial space is an excellent alternative to interscalene block, particularly in hospitals in which an electrical nerve stimulating device is unavailable.

Estudo comparativo, prospectivo e randomizado entre dois métodos de anestesia para cirurgia do ombro

aBstRaCt Objective: To evaluate the efficacy of suprascapular nerve block in combination with the infusion of anesthetic into the sub-acromial space compared to an interscalene block. Methods: Forty-five patients with small or medium isolated supraspinatus tendon lesions who underwent arthroscopic repair were pro-spectively evaluated and randomly assigned to three groups of 15, each with a different combination of anesthetic methods. The efficacy of post-surgical analgesia was measured using the visual analogue scale for pain, and analgesic, anti-inflam-matory, and opioid drug consumption. Inhalation anesthetic consumption during surgery was compared among the groups. Results: Statistical analysis found no significant differences among the groups regarding anesthetic consumption during surgery or postoperative analgesic efficacy during the first 48 hours. Conclusion: Suprascapular nerve block with infusion anesthetic into the subacromial space is an excellent alternative to interscalene block, particularly in hospitals where a nerve stimulator device is unavailable.

High-frequency submaximal stimulation over muscle evokes centrally generated forces in human upper limb skeletal muscles

Control of posture and movement requires control of the output from motoneurons. Motoneurons of human lower limb muscles exhibit sustained, submaximal activity to high-frequency electrical trains, which has been hypothesized to be partly triggered by monosynaptic Ia afferents. The possibility to trigger such behavior in upper limb motoneurons and the potential unique role of Ia afferents to trigger such behavior remain unclear. Subjects (n = 9) received high-frequency trains of electrical stimuli over biceps brachii and flexor pollicis longus (FPL). We chose to study the FPL muscle because it has weak monosynaptic Ia afferent connectivity and it is involved in fine motor control of the thumb. Two types of stimulus trains (100-Hz bursts and triangular ramps) were tested at five intensities below painful levels. All subjects exhibited enhanced torque in biceps and FPL muscles after both types of high-frequency train. Torques also persisted after stimulation, particularly for the highest stimulus intensity. To separate the evoked torques that resulted from a peripheral mechanism (e.g., muscle potentiation) and that which resulted from a central origin, we studied FPL responses to high-frequency trains after complete combined nerve blocks of the median and radial nerves (n = 2). During the blocks, high-frequency trains over the FPL did not yield torque enhancements or persisting torques. These results suggest that enhanced contractions of central origin can be elicited in motoneurons innervating the upper limb, despite weak monosynaptic Ia connections for FPL. Their presence in a recently evolved human muscle (FPL) indicates that these enhanced contractions may have a broad role in controlling tonic postural outputs of hand muscles and that they may be available even for fine motor activities involving the thumb.

Lidocaine Lollipop for Awake Fiberoptic Bronchoscopy

Numerous techniques and maneuvers have been described to anesthetize the upper airway in preparation for awake tracheal intubation, notably the nerve block techniques to the superior laryngeal or the glossopharyngeal nerves as well as the topical application of a local anesthetic, in the form of a gel, spray, or inhaler.1The current report describes the efficacy of a lollipop containing 150 mg lidocaine HCl for providing upper airway analgesia for patients undergoing awake fiberoptic bronchoscope (FOB) tracheal intubation or direct laryngoscopy.After extensive search through Medline and multiple other databases about the stability of lidocaine HCl salt, a lidocaine lollipop (LL) was developed in collaboration with the pharmacy at the American University of Beirut. Fifty grams of white sugar was heated until liquefied; an equal amount of maple golden syrup was slowly added. For each lollipop, 3 ml of this mixture was poured into a small cylindrical container, to which 150 mg lidocaine HCl salt was added and stirred. As the temperature cooled down and before the mixture solidified, a small plastic stick was plunged at one end for holding the LL. The ready-to-use LL was then labeled and stored in a refrigerator.The protocol used was approved by the internal review board, and informed consent was obtained from all participants. Exclusion criteria consisted of any history of allergic reaction to local anesthetics, diabetes, or risk for aspiration of gastric contents. All participants had noninvasive serial blood pressure measurements, pulse oximetry, and continuous electrocardiographic monitoring. A total of 45 patients aged 25–78 yr, with American Society of Anesthesiologists physical status I–III, scheduled to undergo elective surgery and requiring general anesthesia and tracheal intubation were recruited. Premedication consisted of 5 mg oral diazepam and 0.2 mg intramuscular glycopyrrolate. All patients were given the LL on arrival to the holding area. The LL was easily consumed by all patients in 8–17 min. Its taste was described as good in more than 80% of patients and acceptable in the remaining participants. The onset of analgesia as depicted by sensation of tongue numbness was reported within 1–2 min.After finishing the whole LL, and without any additional sedatives, patients were transferred to the operating room. Thirty of the 45 patients underwent awake FOB intubation. A single anesthesiologist introduced a No. 80 Berman intubating oral airway, advanced the FOB (3.8 mm Olympus LF2; Olympus Corporation, Lake Sweeney, NY) to the level of the vocal cords, and injected 2 ml lidocaine HCl, 2%, via the working channel to anesthetize the vocal cords and the trachea. The FOB was then advanced into the trachea, and the endotracheal tube was slid over the insertion cord of the FOB into the trachea.In case of inability to perform FOB-guided intubation, 1 mg midazolam and 1 μg/kg fentanyl were administered intravenously, and then the FOB intubation was reattempted.Tracheal intubation using the FOB was easily performed in 93.4% of patients with minimal or no discomfort, with no associated hemodynamic changes, and without the need for additional sedation. Furthermore, the incidence of gagging and discomfort that warranted additional sedation was observed in only 6.7% of patients, as compared with the reported 9.5% for topical analgesia, 10.5% for nerve block techniques,2or 8% for combined nerve block and topical anesthesia techniques.3In the remaining 15 patients, an awake direct laryngoscopy in an attempt to visualize the vocal cords was performed. General anesthesia was then administered whether direct laryngoscopy and vocal cord visualization were successful or not. The incidence of gagging and failure of direct rigid laryngoscopy was significantly higher than that observed during FOB (46.7% vs. 6.7%, respectively). This may be due to the higher number of pressure receptors recruited during awake direct laryngoscopy than during the awake FOB-aided intubation.In conclusion, the LL containing 150 mg lidocaine may provide a simple, noninvasive, hands-free, effective technique for awake FOB-aided tracheal intubation. The observed effectiveness of the LL technique could be explained by the continuous release of lidocaine from sucking the LL, in addition to swallowing of the saliva mixed with the local anesthetic. This allows for the homogenous spread of the local anesthetic, not only to the mucosa of the oropharynx, but also to the posterior third of the tongue, the area that contains the deep pressure receptors responsible for the gag reflex.1*American University of Beirut Medical Center, Beirut, Lebanon. chakib.ayoub@aub.edu.lb

The effect of compression and regional anaesthetic block on referred pain intensity in humans

The mechanisms underlying local and referred muscle pain are poorly understood. The aim of this experiment was to determine to which degree referred pain is dependent on peripheral or central mechanisms. This was studied by blocking sensory input from the referred pain area. Intramuscular electrical stimulation in the right anterior tibial muscle induced local muscle pain and referred pain in 12 subjects. Nerve blocks were applied on the lower limb between the local and the referred pain area for 60 min. Three different studies were performed: (1) no nerve block (2) compression block, and (3) compression block combined with intravenous regional anaesthesia. The referred pain intensity was assessed every 5 min. To monitor the blockade of myelinated and unmyelinated nerve fibres, touch, pinprick, position sense and heat and heat-pain detection thresholds were assessed on the dorsal side of the foot every 5 min. A significant reduction in referred pain intensity (40.5%) compared with the control experiment was found after 40 min with the compression ischemia nerve block until release of the tourniquet. In the combined nerve block experiment, a significant reduction of referred pain intensity (38.5%) was seen after 20 min and until the release of the tourniquet. There was no significant difference in the referred pain intensity between the two types of blocks. The present findings suggest that both peripheral and central mechanisms play a role in referred pain and that the myelinated fibres mediate the peripheral component.