Use Of Peripheral Nerve Blocks Research Articles

Incidence of acute compartment syndrome with routine use of regional anesthesia for patients with long bone fractures: a large single-center retrospective review from a level I trauma tertiary academic institution

IntroductionTraditionally, using peripheral nerve blocks (PNBs) in patients with long bone fractures has been limited due to concerns that it may interfere with the timely diagnosis of acute compartment syndrome...

Opioid and Nerve Block Administration in Knee Arthroplasty: An Observational Retrospective Evaluation

AimsIncreasing opioid-related adverse events and deaths have amplified interest in non-opioid analgesic options. Peripheral nerve blocks (PNBs) are useful in pain management, especially in minimally invasive day surgeries. This evaluation sought to examine patterns of opioid use among adult patients undergoing total knee arthroplasty, stratified by use of PNBs. DesignA retrospective, observational design. SettingsA large tertiary medical center and community hospital in the Inland Northwest. Participants/SubjectsA dataset of 8,493 adult patients undergoing elective total knee arthroplasty, 3,432 of which received a PNB while 5,061 did not. MethodsA deidentified dataset was obtained to evaluate: (a) opioid use frequency, (b) average morphine milligram equivalents (MMEs) administered, (c) independent factors associated with opioid administration, and (d) time to first opioid administered in adults undergoing total knee arthroplasty while in the recovery room, stratified by use of PNBs. ResultsWhen controlling for general anesthesia, opioid use frequency was reduced when PNBs were administered (p < .05). The amount of MMEs consumed was 15 mg less in the group receiving a PNB (p < .001). In a linear regression model, PNBs reduced the MMEs consumed by 5 mg (p = .014). Time-to-first opioid was increased in patients receiving general anesthesia and PNBs with a hazards ratio of 0.70 (p < .001). ConclusionsPeripheral nerve blocks are an opioid-sparing technique in adult patients undergoing total knee arthroplasty. Clinical ImplicationsThe results confirm best practices regarding opioid-sparing PNBs. Postoperative opioids are appropriate, but regimens incorporating PNB administration for total knee arthroplasty help reduce opioid use.

Chronic postsurgical pain in children and young adults with cancer and choice of regional anesthesia for amputation and limb-sparing surgery.

Patients undergoing limb amputation (LA) or limb-sparing (LS) for lower extremity oncologic diagnoses are at similar risk for chronic postsurgical pain of neuropathic nature (CPSP/NP). Regional anesthesia (RA) techniques are pre-emptive measures to prevent the occurrence of the CPS/NP. However, recommendations for epidural (EP) versus peripheral nerve blocks (PNBs) lack in pediatric literature. This study investigates the incidence and duration of CPSP/NP and describes NP-directed regimens. Data on demographics, use of EP or PNB, duration of CPSP/NP, and NP-directed medication were retrospectively collected for LA and LS between 2009 and 2019. Mixed effects logistic regression was used to compare the odds of CPSP/NP between EP and PNB. Cox PH model with adjustment for clustering due to multiple surgeries on patients was used to quantify rate of pain relief between surgery groups (LA vs. LS) and RA groups (EP vs. PNB). The incidence of CPSP/NP was 36 (23.8%) after 165 surgeries (150 patients). The odds of CPSP/NP after PNB were 2.5 times those of CPSP/NP after EP (p=.11). The rate of pain relief at any instant after the EP was 1.2 times that after PNB (p=.3). The rate of pain relief for LS with EP was 1.9 times that of pain relief for LA with EP, a statistically significant difference (p=.03). Gabapentin was used (94.5%), with addition of amitriptyline (24.2%) and both amitriptyline and methadone (12.7%). The LS with the EP group had a significantly higher rate of relief of CPSP/NP than LA with EP. Odds of CPSP/NP after PNB were 2.5 times those of CPSP after EP.

S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial.

Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.

Association of peripheral nerve blocks with patient-reported quality of recovery in female patients receiving breast cancer surgery: a systematic review and meta-analysis of randomized controlled studies.

This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery. Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40). Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I2 = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I2 = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups. Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia. PROSPERO (CRD42021272575); first submitted 9 August 2021.

Regulation and Selective Utilization of Peripheral Nerve Blocks Decrease Residual Neurological Symptoms After Pediatric Knee Surgery

Background:Peripheral nerve blocks (PNBs) are an essential tool for reducing postoperative pain, but they have recently been associated with a higher incidence of complications than previously thought.Hypothesis/Purpose:We compared 1) incidence of PNB-related postoperative neurological symptoms and 2) patient selection, operative practices, and anesthetic practices regarding PNBs for pediatric patients who underwent knee surgery before and after changes in administration of PNBs at our institution.Methods:We compared data from pediatric patients who underwent knee surgery with PNBs at our institution during 2 periods: 2014–2016 (Cohort 1; 100 patients) and 2017–2019 (Cohort 2; 104 patients). Cohort 1 was described in a previous study, and Cohort 2 consisted of consecutive patients treated by 1 orthopaedic surgeon after recognition of the higher rate of complications and limiting use of PNBs to an anesthesia service at our institution. We compared cohorts using Student t-tests and chi-squared tests. P < 0.05 was considered significant.Results:The incidence of PNB-related neurological complications was significantly lower in Cohort 2 (0.96%; n = 1) than in Cohort 1 (6%; n = 6) (p = 0.045). The 1 patient in Cohort 2 had numbness proximal to the knee, which resolved by 9.5 weeks postoperatively. Of the 6 patients in Cohort 1, 5 also had numbness proximal to the knee, and 1 had shooting pains down the leg upon palpation of the femoral block site. Three of these patients had unresolved symptoms at final follow-up. There was a greater proportion of female patients in Cohort 2 (57%) than in Cohort 1 (36%) (p = 0.01), with no significant differences in age or BMI. The Cohort 2 surgeries also had significantly longer average operating times and a higher proportion using tourniquets (p<0.01). More fellows (67% vs. 55%) and fewer residents (6.9% vs. 16%) performed PNBs in Cohort 2 than in Cohort 1 (p = 0.01). The most common anatomical site for PNBs was the femoral nerve (51%; n = 85) in Cohort 1 and the saphenous nerve (51%; n = 90) in Cohort 2 (p < 0.01).Conclusions:The incidence of PNB-related complications after pediatric knee surgery was significantly lower after our institution implemented changes in the regulation of PNB use. This reduction may be explained by a shift toward more experienced providers administering PNBs and preference for distal anatomic sites, which may suggest actionable items for other institutions aiming to lower their PNB complication rate.TABLE 1.Patient and Surgical Characteristics for Knee Surgeries Performed with PNBs at a Single Institution Before and After Institutional Changes in PNB Regulation and UseTABLE 2.Procedural Characteristics for 341 PNBs Performed During Knee Surgery at a Single Institution Before and After Institutional Changes in PNB Regulation and Use

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study.

Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy. We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB. There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21). Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BackgroundEvidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.MethodsA systematic review and meta-analysis: randomized controlled and observational studies investigating the impact...

588 Peripheral Nerve Blocks in Procedural Care for Burn Injuries Less Than 10% Total Burn Surface Area: A Retrospective Chart Review.

Abstract Introduction Pain control remains one of the major challenges in management of burn patients. Pain associated with procedural and post-procedural burn care such as excision and grafting, postoperative dressing changes, and postoperative physical therapies often requires patients to be on intravenous and oral analgesics leading to potential long-term dependence after hospital discharge. Peripheral nerve blocks (PNB) use for perioperative pain management in burn patients may present an alternative pain management modality to help decrease analgesic consumption and shorten length of stay following procedural care. Our hypothesis was tested by evaluating the outcomes from implementation of PNB with ultrasound guided catheter placement for burn procedural care in patients with ≤ 10% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we retrospectively collected demographics, medical history, pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), postoperative analgesic consumption and time to hospital discharge of patients who underwent autografting procedures for burn injuries ≤ 10% TBSA from October 1, 2019 to December 31, 2019 (the start of our implementation of PNB for procedural burn care). Data was analyzed using chi square/Fisher exact test for categorical variables and t-test for continuous variables. Results Our preliminary data included 20 patients (10 patients had PNB) with average age of 53 years, 60% males and average TBSA of 4.8%. Patients in both PNB and non-PNB groups had unremarkable medical histories and scald and flame as mechanism of burns. There was no significant difference in TBSA (5.3% TBSA in PNB and 4.8% TBSA in non-PNB). Pain intensity before autografting procedure for both groups were reported as moderate to severe and managed with fentanyl, morphine, oxycodone, along with ibuprofen and acetaminophen. There was no significant difference in postoperative pain intensity and opioid consumptions; however, postoperative acetaminophen consumption was less in PNB group compared to non-PNB group (2762±3646 mg vs 3932±7511 mg, respectively), although not statistically significant. There was no significant difference between time from surgery to first physical therapy session; however, time to hospital discharge was shorter in PNB group compared to non-PNB group (5.7±1 days vs 10.5±9 days, respectively), although not statistically significant. Conclusions This evaluation shows a trend in reduction of inpatient postoperative analgesic consumption as well as time to hospital discharge with the use of PNB, although a bigger sample size is needed for further assessment.

Effect of peripheral nerve blocks on postanesthesia care unit length of stay in patients undergoing ambulatory surgery: a retrospective cohort study

BackgroundPeripheral regional anesthesia and analgesia may increase the efficiency of ambulatory surgical centers by reducing pain and preventing nausea and vomiting, which are important modifiable causes of prolonged postanesthesia care...

An Innovative Pain Control Method Using Peripheral Nerve Block and Patient-Controlled Analgesia With Ketorolac After Bone Surgery in the Ankle Area: A Prospective Study

Although postoperative pain is inevitable after bone surgery, there is no general consensus regarding its ideal management. We hypothesized that the combination of ultrasound-guided peripheral nerve block (PNB) and patient-controlled analgesia (PCA) with ketorolac would be useful for pain control and reducing opioid usage. This prospective study aimed to evaluate the effectiveness of this method. This study included 95 patients aged >18 years who underwent bone surgery in the ankle area from June to December 2018. All operations were performed under anesthetic PNB, and additional PNB was given for pain control ∼11 hours after preoperative PNB. An additional PCA with ketorolac, started before rebound pain was experienced, was used for pain control in group A (49 patients) but not group B (46 patients). We used intramuscular injection with pethidine or ketorolac as rescue analgesics if pain persisted. A visual analogue scale (VAS) for pain was used to quantify pain at 6, 12, 18, 24, 36, 48, and 72 hours postoperatively. Patient satisfaction was assessed, along with side effects in both groups. VAS pain scores differed significantly between the groups at 24 hours after the operation (p = .013). All patients in group A were satisfied with the pain control method; however, 5 patients in group B were dissatisfied (p = .001), 3 owing to severe postoperative pain and 2 owing to postoperative nausea and vomiting. An average of 0.75 and 11.40 mg pethidine per patient was used in groups A and B, respectively, for 3 days. We concluded that the combined use of ultrasound-guided PNB and PCA with ketorolac can be an effective postoperative method of pain control that can reduce opioid usage.

Peripheral Nerve Block Use in Ankle Arthroplasty and Ankle Arthrodesis: Utilization Patterns and Impact on Outcomes

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are often associated with significant postoperative pain; this may be mitigated by the use of peripheral nerve blocks (PNB). While smaller studies suggest PNB to be an effective pain management option in foot and ankle procedures, large scale comparative effectiveness data in ankle arthrodesis and TAA is lacking. Therefore, the purpose of this national study was to evaluate PNB utilization patterns and its impact on outcomes such as opioid utilization.Methods:This retrospective cohort study utilized data from the nationwide Premier Perspective claims database (2006-2016) on AA (n=10,049) and TAA (n=4,977) procedures. Mixed-effects models estimated associations between PNB use (defined from inpatient billing) and opioid utilization (during the total hospitalization period and specified by each day), hospitalization costs, length of stay (LOS), admission to skilled nurse facility (SNF), opioid-related complications, and 90-day readmission. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI).Results:Overall, PNB was utilized in 8.6% of TAA and 8.5% of AA. Both procedures demonstrate increased utilization of PNB from 2006 to 2016 (2.7% to 11.7% and 5.5% to 11.7% for TAA and AA, respectively). In general, PNBs were utilized less in non- teaching and smaller hospitals and among surgeries performed by a podiatrist (compared to orthopaedic surgeon). After adjustment for relevant covariates, PNB use was significantly associated with decreased opioid utilization during the total hospitalization period for both TAA (-15.7%, CI 22.8; 7.9%) and AA (-16.0%, CI 21.9%; 9.7%); this was particularly driven by a decrease in opioid utilization on the day of surgery. PNB use was not associated with reductions in LOS, cost of hospitalization, discharge to SNF, complications, 90-day readmission.Conclusion:In this first national study on PNB use in ankle procedures we found an overall low use of PNB while an increasing trend in utilization was observed. Importantly, PNB use was associated with significant opioid-sparing effects (especially on the day of surgery), while no effects were seen for other outcomes. Given the current low utilization rate, increased use of this analgesic technique may translate into more benefits in terms of clinical outcomes and resource utilization.

Can Combination of Peripheral Nerve Block and Non-opioidal Patient Controlled Analgesia Be an Effective Postoperative Pain Control Method?

Category:Ankle, Pain medicineIntroduction/Purpose:Even though bone surgery is very painful after operation, there is no established method to control postoperative pain due to efficacy and side effects. Ultrasound-guided peripheral nerve block (PNB) and nonsteroidal anti- inflammatory drugs (NSAIDs) patient controlled analgesia (PCA) can effectively control pain and reduce side effects.Methods:We conducted a prospective study of 150 patients over 18 years of age who underwent bone surgery from June 2018 to December 2018. All operations were performed under anesthetic ultrasound-guided PNB and additional PNB was performed to control postoperative pain. Among the 120 patients who participated in the final study, NSAIDs PCA was used in group A (65 patients) and NSAIDs PCA was not used in group B (55 patients) for pain control. Postoperative management except PCA was same in both groups. Pain scores are measured at 6, 12, 18, 24, 36, 48, and 72 hours after the operation and they were compared using visual analogue scale (VAS) pain scores. Survey was done on satisfaction of patients, and their willingness to reconsider same method of pain control when they undergo same surgery next time. Also, we evaluated possible side effects that might happen during process of controlling pain.Results:VAS pain score were significantly different only at 24 h postoperatively (p=0.004). In Group A, three patients were prescribed 3 amples of pethidine intramuscular injection as rescue analgesic. In group B, 35 patients were prescribed 50 amples of pethidine and 12 patients of them were received additional 18 amples of ketorolac intramuscular injection as rescue analgesic(p=0.000). In group A, all patients were satisfied with the pain control method, but 5 of the group B patients were dissatisfied (p=0.001). 3 patients responded to severe pain after operation and 2 of them due to postoperative nausea and vomiting (PONV). In group A, there were no patients complaining of PONV, but in group B, 5 patients complained of symptoms (p=0.018), and 3 of them were prescribed additional antiemetics (p=0.093).Conclusion:Combined use of ultrasound-guided PNB and NSAIDs PCA seems to be an effective postoperative pain control method in foot and ankle surgery. Because, pain can be effectively controlled and PONV can be reduced.

Nerve blocks in paediatric and adolescent headache disorders.

Headaches in children and adolescents are common, causing debilitating symptoms in many. Treatment of headache disorders can be complex and standard lifestyle changes as well as oral medications may offer inadequate relief. The purpose of this article is to review the mechanism of action, efficacy and technique of peripheral nerve blocks (PNBs) and the role they play in treating paediatric headache disorders. Evidence for the use of PNBs in youth is limited. However, available studies show evidence of benefit in both primary and secondary headache disorders. Variability exists in the type of block, medication choice, volume infused and frequency of this treatment. There are no serious side effects associated with PNBs. PNBs are well tolerated and effective as adjunctive therapy for many disabling paediatric headache disorders. The technique can be easily learned by frontline and specialty practitioners. Prospective placebo-controlled studies are needed to determine how to best maximize PNBs for headache management (i.e. medication choice, timing and so on).

Outcomes After Peripheral Nerve Block in Hip Arthroscopy.

Pain control following hip arthroscopy presents a significant clinical challenge, with postoperative pain requiring considerable opioid use. Peripheral nerve blocks (PNBs) have emerged as one option to improve pain and limit the consequences of opioid use. The purpose of this study is to provide a comprehensive review of outcomes associated with PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications. A systematic review of PubMed, Medline, Scopus, and Embase databases was conducted through January 2015 for English-language articles reporting outcome data, with 2 reviewers independently reviewing studies for inclusion. When available, similar outcomes were combined to generate frequency-weighted means. Six studies met the inclusion criteria for this review, reporting on 710 patients undergoing hip arthroscopy. The mean ages were 37.0 and 37.7 years for the PNB and comparator groups, respectively, with a reported total of 281 (40.5%) male and 412 (59.5%) female patients. Postoperative post-anesthesia care unit (PACU) pain was consistently reduced in the PNB group, with the use of a lower morphine equivalent dose and lower rates of inpatient admission, compared with that in the control groups. Postoperative nausea and/or vomiting as well as PACU discharge time showed mixed results. High satisfaction and few complications were reported. In conclusion, PNB is associated with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions, though similar rates of nausea/vomiting and time to discharge were reported. Current PNB techniques are varied, and future research efforts should focus on examining which of these methods provides the optimal risk-benefit profile in hip arthroscopy.

Residual Neurological Symptoms After Peripheral Nerve Blocks for Pediatric Knee Surgery.

Peripheral nerve blocks (PNBs) provide excellent pain control and reduce the need for systemic analgesics in orthopaedic surgery. PNBs rarely cause complications; however, a few studies of adults have reported neurological complications during the early postoperative period. We investigated complications associated with the use of PNBs during pediatric knee surgery. We reviewed the medical records of all 121 children (aged ≤18 y) who underwent knee surgery by 1 orthopaedic surgeon between October 2014 and September 2016. One hundred of these patients had PNBs. The primary outcome of interest was postoperative neurological symptoms. Other study parameters were patient characteristics, surgical details, tourniquet use/duration of use, PNB guidance method and anatomic location, and PNB-associated procedural complications (eg, blood loss, anesthetic neurotoxicity). Data were analyzed using Student t tests and Fisher exact tests, with significance at P<0.05. Of the 100 patients with PNBs, 23 had persistent lower-extremity paresthesias postoperatively. Most paresthesias were attributed to the surgical procedure; however, at first follow-up (mean, 1.6±0.4 wk) 6 patients had paresthesias and other neurological symptoms proximal to the knee in a distribution pattern consistent with the PNB. Three of these were unresolved at last follow-up (mean, 56±37 wk). All neurological symptoms were associated with femoral nerve blocks. The 6 patients with suspected PNB-associated neurological symptoms had a significantly higher mean BMI (31±5.5) than the 94 patients without symptoms (23±6.1; P=0.002). Obesity was associated with PNB-associated neurological symptoms (P=0.002), as was female sex (P<0.001). No significant differences were found in terms of age, surgery duration, or tourniquet use/duration of use. Most PNB procedures used ultrasound guidance, and no procedural complications were reported. Compared with previous studies, we report a higher rate (6%) of PNB-associated neurological symptoms in children after knee surgery with PNBs. Obesity and female sex were associated with persistent neurological symptoms in the distribution pattern of the PNB. Level III (retrospective comparative study).

Peripheral nerve blocks for above knee amputation in high-risk patients

Background and Aims:Above knee amputation (AKA) is associated with considerable mortality and morbidity. There is paucity of data describing the use of peripheral nerve blocks (PNB) as the sole anesthetic technique in high-risk patients undergoing AKA. Our objectives were to evaluate the use of PNB as sole anesthetic technique in the above-mentioned population and its clinical outcomes.Material and Methods:This was a retrospective descriptive study conducted in a tertiary hospital. For this study, patients with American Society of Anesthesiologist [ASA] IV physical status underwent AKA using PNB between January 2010 and December 2016, were identified. The primary outcome measured was the success of the operation. The secondary outcomes were block details, intraoperative hemodynamics, usage of sedation and analgesia, patients’ comorbidities, mortality rates at 30 days and one year.Results:Out of fifty-seven patients, the median age (interquartile range) was 74 (57 – 81) years and 60% were males. The results show 91% successfully underwent surgery with PNB (95% CI 81% to 96%). 95% required intraoperative sedation and analgesia. 67% received combined femoral, obturator and sciatic nerve blocks, in which nine cases had an additional lateral femoral cutaneous nerve block. Interestingly, 33% only received combined femoral and sciatic nerve blocks, and they required higher sedation analgesia (p = 0.013). The 30-day and one-year mortality were 12.3% & 47.4%. Majority had stable hemodynamics during the surgery.Conclusion:This study shows that PNB is a viable option for reliable anesthesia for AKA in high-risk patients. Combined FOS nerve block would reduce the dose for sedation–analgesia during the operation.

Peripheral Nerve Blocks for the Lower Extremity

Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks. This review contains 35 figures, 11 tables, 5 videos, and 103 references. Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

Peripheral Nerve Blocks for the Lower Extremity

Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks. This review contains 35 figures, 11 tables, 5 videos, and 103 references. Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

A Two-Year, Prospective, Blinded Analysis of Complications Following Peripheral Nerve Blocks in Foot and Ankle Surgery

Category: Other Introduction/Purpose: Previous data shows complications related to peripheral nerve blocks (PNBs), the standard of care in anesthesia for foot and ankle surgery, occur infrequently. Elucidating the extent of these complications after lower extremity procedures will help improve the safety and quality of care delivered. The purposes of this study were to report the incidence and type of PNB-related complications, and to understand how the type of PNB, specifically popliteal and ankle blocks, may affect these complications. This is the largest prospective study to date and the first to review complications in a blinded fashion by both an unassociated surgeon and anesthesiologist. We hypothesized complications would be rare and mostly resolvable. Methods: Patients undergoing foot and ankle surgery with a PNB were prospectively enrolled for two years and followed postoperatively for three months or until the resolution of complications. Surgery time, tourniquet time, and demographics (age, BMI, sex, comorbidities, and number of surgeries) were collected. A survey was filled out by surgeons at all postoperative visits, and detailed the nature and anatomic location of perioperative complications. Complications were reviewed independently and blindly both by a surgeon and anesthesiologist unassociated with the case and rated as 1) likely from the nerve block, 2) possibly due to the block, or 3) definitely not from the block. Serious complications were defined as those needing an intervention or having a motor deficit, numbness/pain not resolved after 6 weeks, or pain or neuropraxia outside the surgical site. Results: 2,516 patients undergoing 2,704 foot and ankle procedures from October 8, 2012 to October 7, 2014 were identified. Of these, 287 patients (11.4%) had a total of 290 (10.7%) complications after surgery. The majority of surgeries were performed with popliteal block (see table). Complications possibly due to the block were significantly higher in those with a popliteal compared to an ankle block (p &lt; 0.001), but no difference in the complications likely due to the block was found (p=0.522). In complications at least possibly due to the block, dexamethasone additive was a significant predictor (p &lt; 0.001). None of the demographic factors were associated with complications. Interrater agreement between the surgeon and anesthesiologist was found to be 0.42 (weighted kappa statistic), representing agreement on 64.6% of causes of the complications. Twenty serious complications occurred in the 112 possibly block-related complications, 16 of which were unresolved. Conclusion: These findings suggest that the use of PNB in foot and ankle surgery is associated with a low post-operative complication rate and few serious, unresolved complications, most being neurological in nature. The majority of were not attributable to PNBs, but more of the complications possibly due to the block were attributable to popliteal blocks than ankle blocks. The small number of complications made it difficult to draw conclusions about confounders. The relative lack of agreement between the surgeon and anesthesiologist suggests that the cause of complications is commonly not obvious which creates difficulty in studying and managing these patients.