Peripheral Nerve Catheters Research Articles

Interest of peripheral nerve catheters after arthrolysis of the elbow

Interest of peripheral nerve catheters after arthrolysis of the elbow

Development of a Mobile Ultrasound-Guided Peripheral Nerve Block and Catheter Service

Ultrasound guidance is associated with improved efficiency and success of peripheral nerve blockade and a decreased incidence of vascular puncture, making these interventions safer. Patients with peripheral nerve blocks report decreased pain and increased satisfaction scores. We present the development of a mobile ultrasound-guided block service that allows for the safe and efficient placement of nerve blocks and perineural catheters at the nontraditional location of the patient's bedside and in the emergency department.

Tips and tricks to facilitate ultrasound‐guided placement of peripheral nerve catheters in children

To describe an approach to facilitate ultrasound (US)-guided placement of peripheral nerve catheters in children. Continuous peripheral nerve blocks (CPNB) provide excellent surgical anesthesia and postoperative analgesia. However, catheters can be difficult to place, especially in children. Ten US-guided peripheral nerve catheters were placed and placement difficulties encountered were recorded. Four series of 15 consecutive US-guided CPNB were then performed, adding in each series one possible solution to each of the troubles previously encountered. Finally, all maneuvers were employed in the placement of 15 US-guided CPNB in children 3-10 years old and then followed clinically. Initial difficulties encountered were as follows: (i) introducing the catheter, (ii) catheter tip visualization, (iii) length of catheter to be introduced, and (iv) catheter fixation and appropriate long-lasting dressing. The proposed facilitating procedure that addresses each of these difficulties is as follows: (i) three-hand technique: an assistant's hand holds the US transducer, the proceduralist anesthetist slightly withdraws and rotates the needle tip with one hand and advances the catheter with the other, (ii) needle visualization in long axis (LAX) whenever possible with catheter placed inside the needle and US guidance of spread of local anesthetic (LA) through the catheter, (iii) catheter advanced until resistance is found or up to a maximum of 5 cm, and (iv) subcutaneous tunneling of the catheter, Dermabond glue, and careful transparent dressing. All catheters in the last series were 100% effective during surgery and provided complete analgesia for ≥3 days without complications. Continuous peripheral nerve blocks in children should be placed under US guidance in LAX whenever possible, with a three-hand technique and slightly withdrawing or rotating the needle tip to introduce the catheter, administering LA through the catheter, and performing subcutaneous tunneling and careful dressing.

A Survey of Acute Pain Service Structure and Function in United States Hospitals

Although the number of U.S. hospitals offering an acute pain service (APS) is increasing, the typical structure remains unknown. This survey was undertaken to describe the structure and function of the APS in U.S. hospitals only. We contacted 200 non-teaching and 101 teaching U.S. hospitals. The person in charge of postoperative pain management completed and returned the survey. Seventy-four percent of responding hospitals had an organized APS. An APS was significantly more formally organized in academic/teaching hospitals when compared to non-teaching hospitals. Pain assessments included “pain at rest” (97%), “pain on activity” (63%), and reassessment after pain therapy intervention (88.8%). Responding hospitals utilized postoperative pain protocols significantly more commonly in teaching hospitals when compared to non-teaching and VA hospitals. Intravenous patient controlled analgesia (IV-PCA) was managed most commonly by surgeons (75%), while epidural analgesia and peripheral nerve block infusions were exclusively managed by anesthesiologists. For improved analgesia, 62% allowed RNs to adjust the IV-PCA settings within set parameters, 43% allowed RN adjustment of epidural infusion rates, and 21% allowed RN adjustment of peripheral nerve catheter local anesthetic infusion rates.

Bilateral Brachial Plexus Home Going Catheters After Digital Amputation for Patient With Upper Extremity Digital Gangrene

Peripheral nerve catheter placement is used to control surgical pain. Performing bilateral brachial plexus block with catheters is not frequently performed; and in our case sending patient home with bilateral brachial plexus catheters has not been reported up to our knowledge. Our patient is a 57 years old male patient presented with bilateral upper extremity digital gangrene on digits 2 through 4 on both sides with no thumb involvement. The plan was to do the surgery under sequential axillary blocks. On the day of surgery a right axillary brachial plexus block was performed under ultrasound guidance using 20 ml of 0.75% ropivacaine. Patient was taken to the OR and the right fingers amputation was carried out under mild sedation without problems. Left axillary brachial plexus block was then done as the surgeon was closing the right side, two hours after the first block was performed. The left axillary block was done also under ultrasound using 20 ml of 2% mepivacaine. The brachial plexus blocks were performed in a sequential manner. Surgery was unremarkable, and patient was transferred to post anesthetic care unit in stable condition. Over that first postoperative night, the patient complained of severe pain at the surgical sites with minimal pain relief with parentral opioids. We placed bilateral brachial plexus catheters (right axillary and left infra-clavicular brachial plexus catheters). Ropivacaine 0.2% infusion was started at 7 ml per hour basal rate only with no boluses on each side. The patient was discharged home with the catheters in place after receiving the appropriate education. On discharge both catheters were connected to a single ON-Q (I-flow Corporation, Lake Forest, CA) ball pump with a 750 ml reservoir using a Y connection and were set to deliver a fixed rate of 7 ml for each catheter. The brachial plexus catheters were removed by the patient on day 5 after surgery without any difficulty. Patient's postoperative course was otherwise unremarkable. We concluded that home going catheters are very effective in pain control postoperatively and they shorten the period of hospital stay.KeywordsBrachial plexus; Home going catheters; Post-operative pain

Complications of peripheral nerve blocks

Complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist. This review will concentrate on current knowledge about peripheral nerve injury secondary to nerve blocks, complications from continuous peripheral nerve catheter techniques, and local anaesthetic systemic toxicity.

Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-guided Nerve Blockade.

Veterans Affairs Palo Alto Health Care System, Regional Anesthesia and Perioperative Analgesia Service, Palo Alto, California. tedward.kim@va.govBy James R. Hebl, M.D., Robert L. Lennon, D.O., Editors, Adam K. Jacob, M.D., Hugh M. Smith, M.D., Ph.D., Associate Editors, John V. Hagen, Illustrator. New York, Oxford University Press, 2010. Pages: 488. Price: $125.00.The application of ultrasonography to obtain real-time visualization of nerves, vessels, needles, and spread of local anesthetic has recently challenged the traditional methods of performing peripheral nerve blocks (PNB) and has prompted numerous studies to compare their efficiency, efficacy, and safety. Regardless of the method employed, a solid foundation of neuroanatomy is a prerequisite for regional anesthesia. Successful placement of an ultrasound-guided PNB also requires an understanding of ultrasound equipment, principles of sound wave propagation, and scanning techniques to correlate relevant anatomy to its corresponding sonoanatomy. Because of the relatively rapid and recent introduction of ultrasound to regional anesthesia, few currently available textbooks focus on ultrasound-guided nerve-block techniques. The Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-Guided Nerve Blockade is a refreshing book that truly lives up to its name as an atlas and provides a concise, informative review of ultrasound-guided regional anesthesia.The purpose of this book is to be a practical guide to regional anesthesia for residents and practicing anesthesiologists, an overview of ultrasound-guided regional anesthesia, and a review of fundamental principles of ultrasound-guided PNB. The section on ultrasound-guided regional anesthesia consists of three chapters dedicated entirely to the principles of ultrasonography and the application of ultrasound to regional anesthesia, including clear explanations of sound wave propagation and tissue densities, probe selection, and image optimization with changes in frequency, depth, gain, and probe movements (sliding, angling, rotating, tilting, and pressure). These chapters also describe the advantages and disadvantages of in-plane and out-of-plane approaches; use of hydrodissection to avoid nerve trauma from needle contact; employment of color Doppler ultrasound for detecting fluid movement during injection; and common errors, particularly intraneural and intravascular injection. Each chapter in the section on upper extremity and peripheral nerve-block techniques consists of a brief summary of clinical indications for each nerve block; a review of pertinent anatomy; recommendations on patient positioning; description of nerve stimulation technique; and an in-depth explanation of ultrasound-guided techniques, including an evaluation of in-plane and out-of-plane approaches. Each chapter in this section concludes with a discussion of side effects and potential complications. When applicable, the technique of continuous peripheral nerve catheters is also outlined. These focused and succinct explanations, combined with ample images, enable the reader to quickly gain an understanding of basic ultrasound principles and become familiar with various ultrasound-guided techniques.The use of ultrasonography requires correct interpretation of ultrasound images, and this book, aptly titled an atlas, strikes a perfect balance between text and illustration. The study of sonoanatomy is greatly facilitated by detailed and enlarged anatomical illustrations that are juxtaposed with their corresponding ultrasound images on the same page, allowing readers to easily correlate vessels, tendon, muscle, fascia, bone, and nerve. Drawings of patient positioning, probe orientation, and needle introduction also serve as a guide for readers to improve ultrasound image visualization and ergonomics, especially for those new to ultrasound-guided techniques. In addition, the inclusion of nerve stimulation techniques, with supplemental illustrations of relevant anatomy and surface landmarks, can be helpful for those who choose to employ both nerve stimulation and ultrasound-guided techniques.One of the exciting aspects of ultrasound-guided regional anesthesia is the potential for new applications and techniques. With the time lapse inherent in the creation and publication of a textbook, it is unlikely that a single book can keep up with the rapid progress of ultrasound application to regional anesthesia. This book does not include descriptions of all potential ultrasound-guided PNB techniques (e.g. , paravertebral and posterior lumbar plexus blocks), but, although it is not a comprehensive review, it accomplishes its purpose to provide the necessary groundwork for ultrasound-guided PNB. As novel ultrasound-guided PNB techniques are developed, the challenge remains for the clinician to stay informed of the latest innovations.Although many questions about ultrasound-guided regional anesthesia techniques remain, the application of ultrasonography has revolutionized the practice of regional anesthesia in a relatively short time and is here to stay. The Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-Guided Nerve Blockade effectively summarizes the available ultrasound-guided PNB techniques to date and makes a timely entrance as an excellent resource for residents and clinicians. Indeed, the common adage, “a picture is worth a thousand words,” applies seamlessly to this atlas.Veterans Affairs Palo Alto Health Care System, Regional Anesthesia and Perioperative Analgesia Service, Palo Alto, California. tedward.kim@va.gov

Use of epidural and peripheral nerve blocks at the end of life in children and young adults with cancer: the collaboration between a pain service and a palliative care service

Clinicians may avoid continuous pain blocks in pediatric cancer patients at the end of life for fear of complications or of interfering with the desired location of death. To examine the impact of epidural or peripheral nerve catheters on pain control in children and young adults with cancer within the last 3 months of life. We retrospectively reviewed the medical records to assess pain scores, systemic opioid requirements, and impact on death at the preferred location. Ten patients (4.4-21.3 years of age), nine with solid tumors, one with lymphoma, had 14 devices (11 epidural, 3 peripheral nerve catheters) for a range of 3-81 days. Twelve of 13 catheters provided improvement by at least one of three criteria: improved mean pain scores at 24 h (8 of 13) and decreased opioid requirement at 24 h in nine cases and at day 5 in nine cases. Eight patients died in their preferred setting. Six patients had catheters (five epidural, one peripheral) until death, including two who died at home. In some cases, typical contraindications for indwelling catheters (spinal metastasis, vertebral fracture, thrombocytopenia, fever) were superseded by palliative care needs. We found no bleeding, infectious, or neurological complications. Our findings suggest that continuous catheter-delivered pain blockade at the end of life contributes to analgesia, moderates opioid requirements, and usually does not preclude death at the preferred location.

Complications of peripheral nerve catheter removal at home: case series of five ambulatory interscalene blocks

The placement of continuous peripheral nerve catheters on an ambulatory basis is increasing and is routine at our institution. There are few reports of complications associated with peripheral nerve catheter removal in the literature. Described herein is a case series of five patients where complications related to catheter withdrawal were observed. A stimulating catheter with a stainless steel coil surrounded by polyurethane (19-G, 60-cm) exhibited shearing when removal proved difficult in five patients. In four cases, catheter removal by the patients was not possible, requiring them to return to hospital for management. No long-term sequelae were observed in any patient. There can be various causes for difficulty with catheter removal, such as a technical aspect of catheter placement, catheter design, tissue reaction at the catheter site, or a combination thereof. The majority of complications related to outpatient perineural catheters can be handled over the telephone, but our case series may highlight a potential management dilemma in placing continuous stimulating perineural catheters on an ambulatory basis.

An Introductory Curriculum for Ultrasound-Guided Regional Anesthesia: A Learner's Guide.

Northwestern University Feinberg School of Medicine, Chicago, Illinois.bachung@northwestern.eduAn Introductory Curriculum for Ultrasound-Guided Regional Anesthesia: A Learner's Guide. Edited by Brian A. Pollard, B.Sc., M.D., Med., F.R.C.P.C., and Vincent W. S. Chan, M.D., F.R.C.P.C. Toronto, University of Toronto Press UTPRINT, 2009. Pages: 81. Price: $109.00.The burgeoning use of ultrasound imaging to guide the performance of regional anesthesia has breathed new life into an already dynamic and compelling field. The anesthesia residents at my institution have minimal interest in using anatomic landmarks and nerve stimulation alone for guidance in peripheral nerve blocks. It is now all about the ultrasound. As a result, there is a considerable demand for quality resources on ultrasound-guided regional anesthesia for primary learning as well as for reference. This text is well-designed to help meet this need on an introductory level. Its target audience will likely extend from trainees at the beginning of their anesthesia careers to well-seasoned practitioners of regional anesthesia who are only recently incorporating ultrasound imaging as guidance for their peripheral nerve blocks.The text is divided into five sections. The first lays the foundation required for the practice of ultrasound-guided regional anesthesia, a basic science understanding of ultrasound. Because the physics of ultrasound can be tedious and not particularly useful in clinical practice, the authors do not delve deeply into how an electric current will cause a physical transition of a piezoelectrical crystal, for example. Rather, they describe why higher transducer frequencies provide excellent image resolution within superficial tissues and why this is not the case at greater tissue depths. Emphasis on this type of knowledge has direct clinical applications to the attainment of high quality images, and, by extension, successful blocks.Real-time ultrasound imaging elevates a blurry canvas of whites, blacks, and grays to form a cinematic movie showing anatomic structures, and, like holding a camera, one controls the image by guiding the transducer. The authors discuss practical techniques for manipulating the transducer, such as sliding and tilting, to improve the attainment, interpretation, and overall quality of the images. Their favored practice target is one's own forearms, which have a wealth of structures to examine.Included in the first section is a discussion on the use of needles in conjunction with an ultrasound transducer. Using the two in combination is a skill to be gained in its own right. The emphasis on this is critical for the successful and safe execution of regional anesthesia with ultrasound guidance. One useful pearl is for the practitioner to avoid “chasing” the needle while using the in-plane technique but to strive always to guide the needle to the target in the existing optimal image.Only after this introduction are we ready to explore the blocks themselves. The next three sections describe ultrasound-guided nerve blocks in order of increasing complexity. Forearm blocks are discussed along with single-shot femoral nerve blocks as part of the introductory or beginner blocks. The intermediate blocks include the different approaches to target the brachial plexus and sciatic nerve. The final section on peripheral blocks includes a discussion on indwelling peripheral nerve catheters. The fifth, and final, section of the text focuses on ultrasound-assisted neuraxial blocks. The authors make the distinction between “assisted” and “guided,” as these techniques are used mainly to help establish landmarks and depth. True ultrasound guidance depends on real-time images.The recommendations at the end of each chapter are helpful for those wanting or needing further depth in the subject material. The bullet points at the conclusion of each chapter provide a distillation of the most important concepts. The images and illustrations are of high quality and occupy nearly as much real estate as the written text, which is fitting for a book on image guidance. The cross-sectional magnetic resonance images are particularly helpful for those trying to grapple with 2D images in planes they may not be used to visualizing. The book repeatedly highlights the continued need for a solid understanding of anatomy, whether or not ultrasound is employed.In terms of critique, I will return again to a subject that was a rite of passage for all physicians: physics. Although the discussion that relates to ultrasound energy was made brief by intent, it was still not exceptionally clear. However, this is probably because the subject of ultrasound physics itself is not particularly suited to brevity and thus becomes a bit of an impossible task for an introductory guide. Overall, An Introductory Curriculum for Ultrasound-Guided Regional Anesthesia: A Learner's Guide is an easy-to-read, informative text. With an efficiency of words, it remains meaty enough to start feeding the scholarly appetite for ultrasound-guided regional anesthesia and will likely spur further study as well as hands-on practice.Northwestern University Feinberg School of Medicine, Chicago, Illinois.bachung@northwestern.edu

Long-Term Ambulatory Continuous Nerve Blocks for Terminally Ill Patients: A Case Series

Intolerable side effects and dissatisfactory pain control with traditional analgesics prompted the utilization of long-term, ambulatory, continuous peripheral nerve blocks (CPNBs) in terminally ill patients for palliative care. Case series. Continuous peripheral nerve catheters were placed in terminally ill patients in an ambulatory setting. The patients were managed at their homes, with nursing services available to manage the infusions and provide routine monitoring and care. This is a case series of patients with severe peripheral pain and a terminal diagnosis in whom the goals of care were aimed at palliation. All three cases had an unfavorable coagulation status; case 2 had a prior pneumonectomy on the contralateral side and a large tumor on the ipsilateral lung of the continuous brachial plexus block. Interventions included CPNBs, with infusion of local anesthetic. Specific techniques used include cervical paravertebral block and lumbar paravertebral block. After infusion and titration of local anesthetic doses, oral opioid medication was significantly reduced, which resulted in an improved quality of life. The nerve blocks did not hasten death in any of the patients despite their coexisting conditions. CPNBs are a reasonably effective modality to decrease opioid usage when side effects are undesirable for end-of-life care. The risk of unfavorable coagulation status, poor lung function, and risk of infection was outweighed by the benefit in this patient population.

Removal of a knotted stimulating femoral nerve catheter using a saline bolus injection

Stimulating peripheral nerve catheters have become increasingly popular as part of postoperative multimodal analgesia for total knee arthroplasty. We describe a case of a successful nonsurgical removal of a knotted stimulating femoral nerve catheter after saline expansion of the catheter pocket at the bedside. A 65-year-old female underwent total knee arthroplasty under combined spinal epidural anesthesia. Postoperatively, a stimulating femoral nerve catheter was placed without complication. The catheter was threaded 12 cm past the needle tip with minimal resistance. Function of the catheter was verified by loss of pinprick sensation in the femoral nerve distribution and excellent analgesic efficacy was achieved. The first attempt at catheter removal was unsuccessful. Thigh flexion and rotation also failed to facilitate catheter removal. The catheter was then left to continuous tension for 6 hours, but further attempts at removal remained unsuccessful. Under ultrasound visualization, 10 mL of saline was injected through the catheter with moderate resistance and without patient discomfort, after which the catheter was removed using minimal tension. The catheter was intact but had a single knot at the distal end of the catheter. We present a rare case of a knotted stimulating catheter in which the use of a saline bolus to dilate the catheter pocket proved to be successful after other simple methods of catheter removal had failed. Given the simple nature of this technique, it can be attempted at the bedside before more invasive procedures are planned.

Continuous at-home postoperative analgesia using a catheter in the case of hand surgery: Preliminary study about 40 cases

In hand surgery, ever since continuous at-home postoperative analgesia (CPA) was implemented, procedures which cause pain for more than 24 h can now be performed in ambulatory surgery. The aim of our work was to study the feasibility of CPA. Our series comprised 40 patients with a mean age of 50 years. Twenty-four patients had an ASA score of 1 and 16 patients had an ASA score of 2. Indications were osteoarthritis and rheumatoid diseases. Three steps were involved: preoperative (patient screening and information), peroperative (placement of a peripheral nerve catheter through an axillary approach using an elastomeric device) and postoperative (at-home patient care provided by visiting nurses). Evaluation was rated using a CPA score (0 to 10) based on analgesia quality and network organization data. The global CPA score was 1.85. The quality of analgesia (2.6) scored less than the quality of organization (1.1). In the case of analgesia, sleep obtained the lowest score, followed by pain, and lastly, unwanted events. As far as organization was concerned, the network obtained the lowest score, followed by patient satisfaction, and lastly, patient information. Problems were encountered due to insufficient nurse training, analgesia failures, as well as unwanted events related to the oral antalgic treatment. However, technical success was almost always achieved. Our results show that the indications for ambulatory surgery could be extended and hospital-private practice networks be further developed. CPA appears to be a promising technique for analgesia and ambulatory surgery.

Peripheral nerve catheter entrapment is not always related to knotting

To the Editor,We recently experienced a case of difficult nerve cath-eter withdrawal, unrelated to knotting or malpositioning, ina young patient who had undergone major shoulder sur-gery. A 31-yr-old male who was scheduled for arthroscopicshoulder surgery received a right-sided stimulating inter-scalene catheter (Stimucath , Teleflex, Le Faget, France)for postoperative analgesia. Prior to induction of generalanesthesia, the catheter was inserted uneventfully usingnerve stimulator guidance. A C6 response was soughtthrough the stimulating catheter with a current thresh-old

Real-Time 3-Dimensional Ultrasound-Assisted Infraclavicular Brachial Plexus Catheter Placement: Implications of a New Technology

Background. There are a variety of techniques for targeting placement of an infraclavicular blockade; these include eliciting paresthesias, nerve stimulation, and 2-dimensional (2D) ultrasound (US) guidance. Current 2D US allows direct visualization of a “flat” image of the advancing needle and neurovascular structures but without the ability to extensively analyze multidimensional data and allow for real-time manipulation. Three-dimensional (3D) ultrasonography has gained popularity and usefulness in many clinical specialties such as obstetrics and cardiology. We describe some of the potential clinical applications of 3D US in regional anesthesia. Methods. This case represents an infraclavicular catheter placement facilitated by 3D US, which demonstrates 360-degree spatial relationships of the entire anatomic region. Results. The block needle, peripheral nerve catheter, and local anesthetic diffusion were observed in multiple planes of view without manipulation of the US probe. Conclusion. Advantages of 3D US may include the ability to confirm correct needle and catheter placement prior to the injection of local anesthetic. The spread of local anesthetic along the length of the nerve can be easily observed while manipulating the 3D images in real-time by simply rotating the trackball on the US machine to provide additional information that cannot be identified with 2D US alone.

Serum Ropivacaine Concentrations and Systemic Local Anesthetic Toxicity in Trauma Patients Receiving Long-Term Continuous Peripheral Nerve Block Catheters

Ropivacaine is a long-acting local anesthetic used frequently for peripheral nerve blocks and continuous peripheral nerve block catheters. Combat trauma patients at Walter Reed Army Medical Center often receive continuous peripheral nerve block catheters as part of their pain regimen. These catheters remain in situ for several days to weeks. In this study, we evaluated the free ropivacaine drug levels over time in trauma patients by measuring the serum concentration of bound and unbound local anesthetic. The corresponding alpha(1)-acid glycoprotein concentration in patients with prolonged ropivacaine infusions was also measured. Fifteen patients were enrolled in the study; 2 patients were excluded because only a single ropivacaine level was obtained. Of the remaining 13 patients in the study, 2 had peripheral nerve catheters placed at the time of enrollment; the remaining 11 patients had catheters placed before enrollment. These patients were already receiving 0.2% ropivacaine infusions for a period of 18-126 h before the first assessment of local anesthetic level. Catheters infused 0.2% ropivacaine at a rate of 6-14 mL/h; catheter boluses were administered with 0.5% ropivacaine. Local anesthetic blood concentrations were scheduled to be measured on Days 1, 3, 5, 7, and 10 and every 3 days thereafter until all catheters were removed, although not all patients underwent each assessment. Specimens were assayed using high-performance liquid chromatography for total and free serum ropivacaine concentrations. Alpha(1)-acid glycoprotein was also measured. Thirteen patients remained in the study, for a total of 59 blood samples. The median number of days catheters remained in situ for the duration of acute pain therapy was 7 days (range: 6-27 days). The median number of days catheters remained in situ after enrollment into the study was 7 days (range: 4-25 days). The median number of blood samples collected per patient was 4 (range: 2-10 samples). Two patients had isolated increased concentrations of free ropivacaine into a previously identified toxic range with no obvious mitigating factors; both patients had received a 300-mg bolus of 0.5% ropivacaine approximately 24 h before that blood collection. The median ropivacaine concentration over the length of the study was 0.11 mg/L (range: undetectable to 0.63 mg/L). During the first week of the study, the median change in ropivacaine concentration per patient was 0.00 mg/L (range: -0.35 to 0.47 mg/L). Although 2 patients demonstrated isolated serum ropivacaine concentration spikes into a previously identified toxic range, continuous peripheral nerve block catheter management and local anesthetic doses as practiced at Walter Reed Army Medical Center did not result in clinically evident systemic ropivacaine toxicity. There was no correlation between free ropivacaine concentration and alpha(1)-acid glycoprotein concentration except in patients who had already been receiving ropivacaine infusions before entering the study. Despite this lack of correlation, the total duration of local anesthetic infusion did not seem to influence the free concentration of the drug.

Groundbreaking Summit

Groundbreaking Summit

Advanced Regional Anesthesia Morbidity and Mortality Grading System: Regional Anesthesia Outcomes Reporting (ROAR)

A regional anesthesia complication grading system (regional anesthesia outcomes reporting [ROAR]) was developed and applied to 1,213 consecutive patients over a 14-month period. The goal of the project was the creation of a system to standardize complication reporting in the regional anesthesia literature. Patient demographics, status as a war casualty, regional block procedure-specific details, and complication grade were entered into an Internet-based, encrypted Department of Defense database. Regional anesthesia complications were later graded and subcategorized depending on what phase of the block the procedural adverse event took place. One thousand ninety-eight (90.5%) patients had neither regional anesthesia associated technical difficulties or more severe complications. Of a total of 147 cases with adverse events among 115 patients (1.3 per patient), the majority (63.3%, 93/147) were low-grade complications resulting in no significant morbidity. The most common complications resulting in patient morbidity were failed block requiring catheter removal and/or supplemental block (35.4%, 17/48). High grade complications represented only 4.1% (6/147) of all peri-procedural morbidity. These complications included pneumothorax requiring tube thoracostomy, transient laryngeal nerve dysfunction, and cancellation of planned operation after peripheral nerve block or catheter placement. The value of the ROAR system is that it identifies important issues in risk management in regional anesthesia, thereby providing opportunities for further investigation and clinical practice refinement. Furthermore, it provides for a common language when reporting outcomes in the regional anesthesia literature. Use of the ROAR system will provide consistency in outcomes reporting and facilitate comparisons between methods and procedures.

Blood-Stained Combat Boots and Acute Pain Medicine

While still deployed in Afghanistan in support of Operation Enduring Freedom, Rollin “Mac” Gallagher asked me to provide an introduction to the new Acute Pain Management Section in this issue of Pain Medicine . At this point, I have only days left in my deployment. As I pondered this task, my gaze wandered over my rather shabby, blood-stained combat boots. My boots were relatively new when I first arrived but they are now marked with the dust and blood of many trauma calls in this harsh environment. Some of the stains are reminders of challenging resuscitations, some not ending well, but most (>90%) ending in casualty survival. The boots also recall over 190 pain interventions in 3 months and the success of my acute pain mission at Camp Bastion Hospital. I recall the young officer with a below-knee amputation from an improvised explosive device in no pain because of the femoral and sciatic continuous peripheral nerve catheters. The soldier with severe back pain after exposure to a blast, who is provided with enough pain relief from a morphine and ketamine mix, patient-controlled analgesia infusion pump, that he can fly …

A Practical Approach to Regional Anesthesia, 4th Edition.

University of Arkansas for Medical Sciences, Little Rock, Arkansas. ghalebahmed@uams.eduA Practical Approach to Regional Anesthesia, 4th Edition. By Michael F. Mulroy, M.D., Christopher M. Bernards, M.D., Susan B. McDonald, M.D., and Francis V. Salinas, M.D. Philadelphia, Lippincott Williams & Wilkins, 2009. Pages: 356. Price: $85.00.This book is not a traditional textbook that contains considerable detail; rather it is more of a hands-on book intended to provide the practical essentials of regional anesthesia blocks performed in the Virginia Mason Medical Center, Seattle, Washington. The first edition appeared in 1996. This is the fourth edition, which reveals that it has been repeatedly updated to include the rapid development of the practice of regional anesthesia. For example, this edition includes new sections on ultrasound-guided regional anesthesia and the use of peripheral nerve catheters. Both are essential, because they represent very important advances in the practice of regional anesthesia and improve its safety and reliability.I believe that the authors have covered these new advances fairly well in this book, especially in their descriptions of equipment and a variety of regional blocks including the brachial plexus, peripheral nerves of the upper extremity, lumbar plexus, and sacral plexus-sciatic nerves. In comparison to the third edition, this edition has more authors (four authors and one contributor) who have added strength to this book, while the third edition had only one author and two contributors. That 2002 edition had 24 chapters, while this edition has only 23 chapters. In this latest edition, the chronic pain management and obstetrical anesthesia chapters have been removed. A new chapter on the use of regional anesthesia for ambulatory surgery has been added. The 2002 edition had 113 figures and 23 tables, while the 2009 edition has 145 figures and the same number of tables. There is a significant increase in the number of comprehensive figures, diagrams, schemes, and photographs illustrated in the different chapters. These facilitate the reader’s understanding and provide a more pleasant reading experience. A further enhancement is the use of color in figures and tables in this new edition.The book’s first two chapters, Local Anesthetics and Local Anesthetic Clinical Pharmacology, are excellent. The author covers updated local anesthetics pharmacology in a very concise and effective manner. The chapters reviewing complications of regional anesthesia, premedication, and monitoring provide concise and updated ideas relevant to clinical practice, allowing readers to master the essentials of these topics.The chapters dealing with spinal, epidural, and caudal anesthesia are very informative, well written, and updated with recent references. These chapters also include very good illustrations and images. The intercostal and terminal nerve anesthesia of the trunk and the paravertebral chapters were updated in this edition with more references and multiple figures, including advanced ultrasound-guided blocks images. The airway, cervical plexus blocks, ophthalmic anesthesia, pediatric regional anesthesia, ambulatory surgery and postoperative pain management chapters were written in a concise and very informative manner.The block choices and descriptions are supplemented by excellent illustrations as well as photographs of ultrasound guidance, anatomy, surface anatomy, and needle positions. One of my favorite chapters that showed the authors’ experience described anesthesia of the brachial plexus. In the chapters on peripheral nerve blocks of the upper extremity, lumbar plexus blocks, and sacral plexus–sciatic nerve blocks, the authors did a great job of incorporating recent advances in using ultrasound guidance and insertion of catheters. However, they omitted other techniques for performing these blocks, mentioning them only as references. The authors only discussed the use of an in-plane transverse middle scalene approach. These narrowed discussions led me to conclude that the text might be better titled as the Virginia Mason Manual of Regional Anesthesia Techniques.One of the difficulties of rewriting new editions of a textbook is the need to include new and important references. In this case, however, I could not find any important omissions. The book is comprehensive and refreshingly uniform and nonrepetitive. In conclusion, this book is worthy to be included in the library of all anesthesiology departments, especially to support the education of trainee anesthesiologists.University of Arkansas for Medical Sciences, Little Rock, Arkansas. ghalebahmed@uams.edu