Plexus Nerve Block Research Articles

Translated article] Pericapsular nerves block (PENG) is an effective and safe alternative for postoperative pain management after primary total hip arthroplasty: A randomised clinical trial

BackgroundPostoperative pain after total hip arthroplasty can affect postoperative rehabilitation and delay hospital discharge. The objective of this study is to compare pericapsular nerves group (PENG) block with pericapsular infiltration (PAI) and plexus nerve block (PNB) for postoperative pain management, response to physical therapy, opioid consumption, and length of hospital stay after a primary total hip arthroplasty. MethodsRandomised clinical trial of parallel and blinded groups was performed. Sixty patients who underwent elective THA between December 2018 and July 2020 were randomised into the different groups (PENG, PAI and PNB). The visual analogue scale was used to assess pain; and motor function was measured with the Bromage scale. We also record opioid usage, length of hospital stay, and related medical complications. ResultsPain level at discharge was similar in all groups. Hospital stay was 1 day shorter in the PENG group (p<0.001) and they also had lower opioid consumption (p=0.044). Optimal motor recovery was similar in the groups (p=0.678). Pain control when performing physical therapy was better in the PENG group (p<0.0001). ConclusionsPENG block is an effective and safe alternative for patients undergoing THA as it reduces opioid consumption and hospital stay compared to other analgesic methods.

El bloqueo de nervios pericapsulares (PENG) es una alternativa efectiva y segura para el manejo del dolor postoperatorio después de una artroplastia total de cadera primaria: ensayo clínico aleatorizado

BackgroundPostoperative pain after total hip arthroplasty can affect postoperative rehabilitation and delay hospital discharge. The objective of this study is to compare pericapsular nerves group (PENG) block with pericapsular infiltration (PAI) and plexus nerve block (PNB) for postoperative pain management, response to physical therapy, opioid consumption, and length of hospital stay after a primary total hip arthroplasty. MethodsRandomized clinical trial of parallel and blinded groups was performed. Sixty patients who underwent elective THA between December 2018 and July 2020 were randomized into the different groups (PENG, PAI and PNB). The visual analog scale was used to assess pain; and motor function was measured with the Bromage scale. We also record opioid usage, length of hospital stay, and related medical complications. ResultsPain level at discharge was similar in all groups. Hospital stay was 1 day shorter in the PENG group (p<0.001) and they also had lower opioid consumption (p=0.044). Optimal motor recovery was similar in the groups (p=0.678). Pain control when performing physical therapy was better in the PENG group (p<0.0001). ConclusionsPENG block is an effective and safe alternative for patients undergoing THA as it reduces opioid consumption and hospital stay compared to other analgesic methods.

Understanding fascial anatomy and interfascial communication: implications in regional anesthesia.

With the extensive application of ultrasound in regional anesthesia, there has been rapid development of interfascial plane block techniques recently. Compared with neuraxial anesthesia or nerve plexus blocks, the interfascial plane blocks have many advantages, such as technical simplicity, fewer complications and comparable or better analgesia. The concept of fascial interconnectivity is fundamental in understanding the effects and complications of interfascial plane blocks. Many fascial planes are continuous and communicate with each other without a clear anatomical boundary. The prevertebral fascia of the neck, endothoracic fascia of the chest, transversalis fascia of the abdomen, and the fascia iliaca of the pelvic cavity form a natural fascial continuation. This anatomical feature suggests that the space beneath the cervical prevertebral fascia, the thoracic paravertebral space, the space between transversalis fascia and psoas muscles (psoas major and quadratus lumborum), and the fascia iliaca compartment are a confluent potential cavity. Additionally, the permeability of the fascia at different anatomical locations to local anesthetics is different, which can also influence the block effect and the incidence of complications. This article summarizes the anatomical characteristics and communication relationships of the major fascia which are related to regional anesthesia, and their relationships with block effects and complications.

Hepatic Plexus Nerve Block for Microwave Ablation of Hepatic Tumors.

Seven patients underwent microwave ablation of hepatic tumors; during ablation, a hepatic nerve plexus block was used for pain control. The mean visual analog scale (VAS) score for pain (scale, 0-10) was 0.3 ± 0.5 (SD) at baseline and 2.5 ± 1.4, 2.6 ± 1.4, and 2.3 ± 0.9 at 1, 5, and 10 minutes during ablation. Two patients reported a VAS score of 4 or greater during ablation, which improved in both patients to a VAS score of 3 after one rescue sedation dose. The remaining patients required no additional sedation. No major complication occurred. No patient required conversion to general anesthesia.

Nerve Stimulator Guided Lumbar Plexus and Parasacral Sciatic Nerve Block for above Knee Amputation in a High-Risk Patient: A Case Report

Ultrasound guidance is the most widely used nerve localization method of choice for peripheral nerve blocks. It can provide direct visualization of the needle, nerves, and the spread of the local anesthetic improving the success rate. In contrast, nerve stimulation relies on surface landmark identification, and physiological responses of neural structures to electrical stimulation which can be highly influenced by injectates and physiologic solutions affecting its efficacy.

Application of brachial plexus and suprascapular nerve block combined with general anesthesia in shoulder arthroscopy

Objective To investigate the value and advantage of ultrasound guided intermuscular groove and suprascapular nerve block combined with general anesthesia in shoulder arthroscopy. Methods 40 American Society of Anesthesiologists (ASA)Ⅰ-Ⅱ patients undergoing elective arthroscopic shoulder surgery were randomly divided into two groups. Patients in group A were treated with general anesthesia, while patients in group B were treated with brachial plexus and suprascapular nerve block combined with general anesthesia. Mean arterial pressure (MAP), heart rate (HR) and visual analogy score ( VAS) were measured at preoperative (T0), 5 min after the beginning of the surgey (T1), 30 min after the beginning of the surgey (T2), at the end of the surgery (T3), and 30 min after removing laryngeal mask (T4). Bispectral index (BIS) was recorded at T1 and T2. The operation time, extubation time, dosage of opioids (sufentanyl), dosage of propofol, visual analogue scale (VAS) scores at awake time in post anesthesia care unit (PACU), and 6 h, 12 h, 24 h after surgery. Results There were no significant differences in the BIS between two groups at T1 and T2 (P>0.05). Both the MAP and HR had no statistical significance at T0 (P>0.05). MAP and HR in group B were significantly lower than those in group A from T1 to T4 (P<0.05). Compared with group A, patients in group B had significantly shorter extubation time (P<0.05), smaller dosages of sufentanyl and propofol (P<0.05), lower VAS scores at awake time 6 h and 12 h after surgery (P<0.05). Conclusions Brachial plexus and suprascapular nerve block combined with general anesthesia can offer better anesthesia status, reduce dosage of opioids and propofol, and can provide effective analgesia in shoulder arthroscopy. Key words: Brachial plexus block; Anesthesia, general; Ultrasonography; Arthroscopy; Shoulder joint

Effect study of acupressure on preventing uroschesis after mixed hemorrhoid surgery in different periods of time

Objective To compare the effect of acupressure on preventing uroschesis after mixed hemorrhoid surgery in different periods of time, explore the reasonable frequency and time of acupressure applied to mixed hemorrhoid surgery, choose the effective and reasonable massage period for mixed hemorrhoid surgery so as to provide clinical reference. Methods A total of 90 mixed hermorrhoid resection margin patients under partial nerve plexus block anesthesia received in proctology department of this hospital from November 2015 to February 2016 were selected as the study objects and were divided into experimental group 1, experimental group 2 and experimental group 3, 30 cases of each group.For the three groups based on usual care, acupressure was conducted to experimental group 1 30 minutes before surgery, acupressure was conducted to experimental group 2 immediately, and acupressure was conducted to group 3 30 minutes before surgery and immediately.The indexes of the first average urination time, urination condition and lower abdomen symptoms were observed to three groups after treatment. Results Compared with the average urination time and urination condition of the three groups, the difference had no statistical significance(P>0.05). Compared with the lower abdomen symptoms of three groups, the effect of group 3 was obviously superior to group 1 and group 2. The difference had statistical significance(P 0.05). BMI was positively correlated with urination time (P<0.05). Conclusion ①The average urination time of 3 groups after surgery by length is experimental group 3, experimental group 2 and experimental group 1. ② The increase of acupressure frequency can obviously improve the symptoms of lower abdomen. ③ When BMI value of patients is higher, the average urination time will be longer. Key words: Mixed hemorrhoid; Postoperative urine retention; Acupuncture point massage; Nursing intervention

Failed Nerve Blocks: Prevention and Management

Failed Nerve Blocks: Prevention and Management

English

INTRODUCTION: Spinal Anaesthesia is the widely used method for lower limb orthopaedic surgeries, providing a faster onset and effective motor and sensory blockade. It is simple, easy to perform and has got a definite endpoint. Intrathecal bupivacaine is widely used in spinal anaesthesia over a long period of time. In this setting, a newer drug Ropivacaine has emerged, which is being widely used for epidural blocks and nerve plexus blocks. Ropivacaine has an improved safety profile over bupivacaine with respect to central nervous system and cardio toxic potential. Though ropivacaine is being used frequently, in epidural and nerve blocks, the literature regarding its use in intrathecal route is sparse. AIM OF THE STUDY: Intrathecal bupivacaine results in a longer duration of complete anaesthetic block than ropivacaine. Fentanyl used as an adjuvant may improve the quality of spinal block of ropivacaine, while maintaining its advantage of early motor recovery. The aim of the study was to compare the efficacy and safety of intrathecal ropivacaine‑fentanyl (RF) with bupivacaine‑fentanyl (BF) for lower limb orthopaedic surgeries. METHODS: In this Single Centered, Prospective, Randomized, Parallel group, Double – Blind study, sixty patients were randomly allocated to receive either intrathecal 15 mg of 0.5% ropivacaine with 25 mcg fentanyl (Group RF) or 15 mg of 0.5% bupivacaine with 25 mcg fentanyl (Group BF). The onset, duration, spread of sensory and motor block, haemodynamic parameters and side effects were recorded. Data analysis was done by using SPSS software and Sigma Stat 3.5 version (2012). RESULTS: Time to reach highest sensory level, complete motor block and two segment sensory regression time were comparable. The motor recovery to Bromage scale 1 was faster in Group RF. The haemodynamic stability was better in Group RF. Time duration of analgesia was prolonged in Group BF. CONCLUSION: Intrathecal RF provided satisfactory anaesthesia with Haemodynamic stability for lower limb orthopaedic surgeries. It provided a similar sensory but a shorter duration of motor block compared to BF, which is a desirable feature for early ambulation, voiding and physiotherapy.

Patient with Chronic Abdominal Pain from Pancreatitis

Early diagnosis of chronic pancreatitis is possible by combining clinical information with pancreatic function testing, endoscopic ultrasonography, histology, and traditional imaging techniques such as magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Such an approach helps improve the sensitivity and specificity of these complementary modalities. Pain management of chronic pancreatitis involves multidisciplinary and multimodal approaches. Behavioral modifications such as alcohol cessation, nutritional optimization, and cognitive-behavioral therapy play a significant role for better long-term outcomes. Pharmacologic management is directed at relieving both psychological and physical symptoms, and combination pharmacotherapies are often needed to address pancreatic deficiency, abdominal pain, and psychological disorders. Interventional approaches to celiac plexus and splanchnic nerve blocks and denervation (radiofrequency ablation, endoscopic or surgical denervation) may provide significant and prolonged pain relief. Neuromodulation in the form of spinal cord stimulation is a viable option for long-term pain relief. Managing complications of chronic pancreatitis, such as gastrointestinal complications (peptic ulcer, bile duct stenosis), pseudocysts, malnutrition, depression, diabetes, and painful diabetic neuropathy, is an integral part of comprehensive treatment and requires close collaboration between members of a multidisciplinary team. This review contains 1 figures, 2 tables and 64 references Key words: behavioral modifications, celiac plexus, chronic abdominal pain, chronic pancreatitis, interventional therapy, pharmacologic modulation, splanchnic nerves, surgical intervention

Effect of dexmedetomidine given by different routes on combined lumbar plexus and sciatic nerve block with ropivacaine

Objective To evaluate the effect of dexmedetomidine (Dex) given by different routes on combined lumbar plexus and sciatic nerve block(CLPSNB) with 0.375% ropivacaine. Methods Ninety patients were randomly allocated into three groups (n=30): 0.375% ropivacaine 50 ml for CLPSNB in group R, 1 μg/kg Dex infused over 10 min+0.375% ropivacaine 50 ml for CLPSNB in group D+R, and 1 μg/kg Dex diluted in 0.375% ropivacaine 50 ml for CLPSNB in group DR. Groups R and DR were intravenously infused with the same volume of saline in group D+R. The onest time and duration of sensory and motor block, satisfaction of doctors, and side effects were recorded. Results Sensory and motor block onset time has no significant difference among three groups(P>0.05). Motor block duration and first time use of analgesics were longer in group DR[(768±246) min and (1 080±300) min] and group D+R[(732±204) min and (1 050±288) min] than group R[(420±126) min and (840±306) min](P 0.05). Conclusions Dex diluted in 0.375% ropivacaine for CLPSNB can provide good analgesic efficacy and satisfaction of doctors. Key words: Dexmedetomidine; Ropivacaine; Nerve block; Lumbar plexus; Sciatic nerve

Efficacy and Safety of Dexamethasone as an Adjuvant to Local Anesthetics in Lumbar Plexus Block in Patients Undergoing Arthroscopic Knee Surgeries

Background: The benefit of adding dexamethasone in regional anesthesia has recently been the focus of investigation as clinical reports suggest improved block characteristics. The aim of this study is to evaluate whether perineural administration of dexamethasone is more effective in prolonging the duration of lumbar plexus block than giving it systemically. Methods: 60 (out of 72) patients were recruited to undergo arthroscopic knee surgery using lumbar plexus block. These patients were divided randomly into 3 groups, 20 patients in each; group L (combined lumbar plexus and sciatic nerve block with bupivacaine 0.5%), group D (combined lumbar plexus and sciatic nerve block with bupivacaine 0.5%+8mg dexamethasone in LPB ) and group S (combined lumbar plexus and sciatic nerve block with bupivacaine0.5% +8mg intravenous dexamethasone). Results: patients showed statistically significant enhanced onset of sensory loss in group D when compared to group L (p value=0.04) but no statistically significant difference found between groups S and L (p value=0.13) or between groups D and S (p value=0.86). Regarding onset of motor loss it was found that group D enhanced onset of motor block significantly (p value<0.01) when compared to group L, while group S showed statistically insignificant enhancement of onset of motor block when compared to group L (p value=0.15) or group D (p value=0.71). Regarding sensory block duration (Postoperative analgesia), both groups D and S showed significant prolonged duration of analgesia (p value<0.01and0.04 respectively) when compared to group L, but no statistically significance detected when compared to each other (p value=0.24) which means they both similarly prolong duration of analgesia clinically. Motor block duration was significantly prolonged in group D when compared to groups L and group S (p value≤0.01).While group S didn’t show statistically significant prolongation of motor block when compared to group L (p value=0.4). Conclusion: Both perineural and IV administration of dexamethasone improve the efficacy of lumbar plexus block by prolonging the duration of analgesia, enhancing onset action of local anesthetics, and reducing postoperative analgesic requirements without increasing the incidence of complications.

Population pharmacokinetic analysis of bupivacaïne used in regional anaesthesia

Introduction The primary aim of this study was to establish the population pharmacokinetic (PPK) model of bupivacaine after combined lumbar plexus and sciatic nerve blocks and secondary aim is to assess the effect of patient's characteristics including age, body weight, sex and drugs co medication (Clonidine and Propofol) on pharmacokinetic parameters. Materials and method A total of 59 patients scheduled for elective lower extremity surgery with combined lumbar and sciatic nerve block using plain bupivacaine 0.5% were included. The total bupivacaine plasma concentrations were measured before injection and after two blocks placement and at selected time points. Monitoring of bupivacaine was made by high performance liquid chromatography (HPLC) with ultraviolet detection. Non-linear mixed effects modeling was used to analyze the PPK of bupivacaine. This pharmacokinetic model was validated using npde package for statistic software R. The simulations confirm that our final model was valid. Results and discussion Two compartment model with first order absorption, two input compartments, a central elimination and peripheral compartment was selected. The Shapiro-Wilks test of normality for normalized prediction distribution errors for this model ( P = 0.837) showed this as a valid model. The description of the quality of the estimate by the graphic diagnostic suggests a good fitting of the final model. The selected model predicts a population clearance of 503 mL/min (residual standard error [RSE] = 16.5%, 95% CI = [534.9–866.9]) with between subject variability of 93.16%. The central and peripheral volumes of distribution were respectively 6850 L and 120 L. The absorption of bupivacaine in two sites Ka1 and Ka2 were 0.00073/min for the lumbar site and 0.0037/min for the sciatic site. Within subject variability WSV% was 30, 3%. Drug Co medication, age, body weight and sex, have no effect on the bupivacaine pharmacokinetics in this studied population. Conclusion The developed model helps us to assess the systemic absorption of bupivacaine at two injections sites.

Comparison of anesthesia methods for elderly patients undergoing unilateral lower limb surgery

Objective To probe into safety of anesthesia methods for elderly patients undergoing unilateral lower limb surgery.Methods Sixty elderly patients,aged 80 y-99 y,scheduled for unilateral lower limb surgery,were randomly divided into nerve block group (group N) and hypobaric spinal anesthesia group (group S).Group N received lumbar plexus and sciatic nerve block,while group S underwent hypobaric spinal anesthesia.The patients' mean arterial pressure(MAP),the heart rate(HR) and the blood oxygen saturation(SpO2) before the anesthesia as well as the 1,3,5,10,15,30 min,1,2 h after the anesthesia and by the end of the operation.Dose of local anesthetic dosage,onset time of anesthesia complete block time,adjuvant drug,level of sensory block were documented anesthesia effects,side effects and complications were observed.Results MAP,HR and SpO2 in group N were (156±15) mm Hg (1 mm Hg=0.133 kPa),(85±7) beats/min,(98.5±1.5)％(P＞0.05) respectively 10 min after the anesthesia.MAP,HR and SpO2 in group S were (99±11) mm Hg,(99±5) beats/min,(98.5±1.5)％(P＜0.05) respectively 10 min after the anesthesia.There was significant difference in MAP between group N and group S (P＜0.05).No significant difference was detected in HR between two groups.Highly significant difference in group N was found in SpO2 before and after the anesthesia (P＜0.01).There was significant difference in SpO2 in group S before and after the anesthesia.However,no significant difference was detected in SpO2 between two groups.The incidence of hypotension shivering,nausea and vomiting in group S higher (P ＜0.05,P ＜0.01).Conclusions Lumbar plexus and sciatic nerve block is safer than hypobaric spinal anesthesia,for elderly patients undergoing unilateral lower limb surgery.The patients receiving lumbar plexus and sciatic nerve block have more stable,hemodynamics and fewer complications.Lumbar plexus and sciatic nerve block would be one of anesthesia methods for elderly patients undergoing lower limb surgery who areis neither suitable for spinal anesthesia nor general anesthesia. Key words: Lumbar plexus and sciatic nerve block; Elderly patients; Unilateral; Lower limb surgery; Hypobaric spinal anesthesia

Electrical nerve stimulation and locoregional anesthesia: New modalities

Electrical nerve stimulation (ENS) is a proven modality for ascertaining close needle-to-nerve proximity. ENS has been used for decades and has been associated with high success rates and extremely low complication rates. Ultrasonographic (U/S) guidance has been used increasingly to assist in the placement of peripheral and plexus nerve blocks. U/S guidance allows for real-time imaging of the needle, targeted nerve or nerves, and other relevant anatomical structures that are in close proximity. Each modality alone has distinct advantages as well as limitations. Each can be used alone for many regional blocks or the two can be combined, more optimally, to take advantage of the positive attributes of both techniques. Both ultrasonographic imaging equipment and techniques devices used for electrical nerve stimulation continue to evolve, improving success and user friendliness.

Combined lumbar plexus and sciatic nerve block for hip fracture surgery in a patient with severe aortic stenosis

Combined lumbar plexus and sciatic nerve block for hip fracture surgery in a patient with severe aortic stenosis

Spinal anesthesia and combined sciatic nerve/lumbar plexus block techniques in lower extremity orthopedic surgery

In lower extremity orthopedic surgeries, central and peripheral regional anesthesia techniques can be used along with general anesthesia, mainly in elderly patients with accompanying maladies. This study investigates the efficiency of spinal anesthesia and combined sciatic nerve/lumbar plexus block techniques in lower extremity orthopedic surgery in terms of patient-surgeon satisfaction. Fifty consecutive patients (age range: 50-90 years), with an ASA score of 2-3 were scheduled for lower extremity orthopedic surgery. The patients were randomly divided into two groups according to anesthesia type. Group 1 (25 patients) received spinal anesthesia (SA) and Group 2 (25 patients) a combined sciatic/lumbar plexus nerve block (CSLPB). Spinal anesthesia was performed with 3 ml of 0.75% ropivacaine, and the combined sciatic/lumbar plexus nerve block was obtained with 10 ml 0.75% of ropivacaine and 10 ml of normal saline (20 ml in total). We recorded the time elapsed during the administration of the anesthesia and the initiation of its effect. Evaluation was made on patient-surgeon satisfaction. Regional anesthesia duration was significantly longer in the CSLPB group (p<0.0001). The time required to prepare the patients for surgery was statistically and significantly shorter in the SA group (p<0.001). Values of patient and surgeon satisfaction did not significantly correlate (p>0.05). Both standard anesthesia and combined sciatic/lumbar plexus nerve block were effective in lower extremity orthopedic surgeries. Although surgery preparation time was longer in the CSLPB group, patient-surgeon satisfaction was similar in both groups.

Elektrische Nervenstimulation für Plexus- und Nervenblockaden

Despite the increasing use of ultrasound, electrical nerve stimulation is commonly used as the standard for both plexus and peripheral nerve blocks. Several recent randomized trials have contributed to a better understanding of physiological and clinical correlations. Traditionally used currents and impulse widths are better defined in relation to the distance between needle tip and nerves. Commercially available devices enable transcutaneous nerve stimulation and provide new opportunities for the detection of puncture sites and for training. The electrically ideal position of the needle usually is defined by motor responses which can not be interpreted without profound anatomical knowledge. For instance, interscalene blocks can be successful even after motor responses of deltoid or pectoral muscles. Infraclavicular blocks should be aimed at stimulation of the posterior fascicle (extension). In contrast to multiple single nerve blocks, axillary single-shot blocks more commonly result in incomplete anaesthesia. Blockade of the femoral nerve can be performed without any nerve stimulation if the fascia iliaca block is used. Independently of the various approaches to the sciatic nerve, inversion and plantar flexion are the best options for single-shot blocks. Further clinical trials are needed to define the advantages of stimulating catheters in continuous nerve blocks.

Effect of propofol on bupivacaine pharmacokinetic after combined lumbar plexus and sciatic nerve block

Effect of propofol on bupivacaine pharmacokinetic after combined lumbar plexus and sciatic nerve block

197: Effect of propofol on bupivacaine pharmacokinetic after combined lumbar plexus and sciatic nerve block

197: Effect of propofol on bupivacaine pharmacokinetic after combined lumbar plexus and sciatic nerve block