Ultrasound-guided Peripheral Nerve Blocks Research Articles

An injectable oleogel-based bupivacaine formulation for prolonged non-opioid post-operative analgesia.

Opioid-based medications remain the mainstay of post-operative pain management, even though they are associated with a plethora of adverse effects including addiction, nausea, constipation, cognitive impairment, respiratory depression, and accidental death due to overdose. Local anesthetics are effective at controlling the intense pain after surgery but their short duration of effect limits their clinical utility in post-operative pain management. In this manuscript, an optimized injectable oleogel-based formulation of bupivacaine for multi-day post-operative pain management was characterized on the benchtop and assessed in two clinically-relevant porcine post-operative pain models. Benchtop characterization verified the optimized oleogel-based bupivacaine formulation design, demonstrating a homogenous stable oleogel with sufficient injectability due to shear-thinning properties, high drug loading capacity and first-order drug release kinetics over 5days. In vivo assessment in two pig post-operative pain models demonstrated that the oleogel-based bupivacaine formulation can provide statistically significant multi-day analgesia in two routes of administration: local instillation directly into a surgical site and ultrasound-guided peripheral nerve block injection. Pharmacokinetic assessment of ALX005 found that Cmax values were not statistically different from the bupivacaine HCl control, with no clinical signs of local anesthetic systemic toxicity observed, when administering up to 2.7 and 8.1 times the control dose of bupivacaine HCl. This study demonstrates the pre-clinical safety and efficacy of an injectable oleogel-based bupivacaine formulation and explores its utility as a single-administration long-acting local anesthetic product for post-operative pain management that can be used in both local and regional anesthetic applications.

Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings.

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

Ultrasound-Guided Peripheral Nerve Block as Post-Operative Management of Lower Abdominal Surgery in Ksatria Airlangga Floating Hospital

Introduction: Enhanced Recovery After Surgery (ERAS) implementation in remote areas by operating hospital ships is immensely helpful due to high patient turnover, reducing costs, and minimizing the effects of surgical stress. Utilization of regional anesthetics, namely ultrasound-guided Transversus Abdominis Plane (TAP) block or Quadratus Lumborum (QL) block, is applicable and beneficial in this setting. Objective: Due to the limited time, facilities, and health personnel available in floating hospital services surgery, several adjustments in anesthetic methods are required to rapidly return patients to their preoperative physiologic state. Therefore, we wrote this case report. Case Series: We presented case series of lower abdominal surgery performed in Ksatria Airlangga Floating Hospital with the implementation of peripheral nerve blocks as one of the ERAS protocols in one of the remote islands in Indonesia, Gili Iyang Island. Two patients underwent TAP blocks, while the remaining two received QL Blocks. A peripheral nerve block was performed under ultrasound guidance and a 20-mL injection of 0.25% levobupivacaine to QL muscle or TAP. During the observation, we found Visual Analogue Score (VAS) of 1-2 after surgery, no post-operative sedation needed, only 1 patient experienced nausea without vomiting, and the length of health facility stay were less than 3 days. Discussion: Nearly all of our patients who underwent lower abdomen surgery got benefits from the application of peripheral nerve block. Because there was no opioid consumption in our cases, the risk of unwanted effect of opioids like postoperative nausea and vomiting, were also decreased. Conclusion: Peripheral nerve block, as mentioned TAP Block and QL Block, has emerged as a promising alternative to prevent and manage post-operative pain in remote medicine settings, namely Ksatria Airlangga Floating Hospital, particularly in areas with few medical facilities.

Primary outcomes and anticipated effect sizes in randomised clinical trials assessing adjuncts to peripheral nerve blocks: A scoping review.

Prolonging effects of adjuncts to local anaesthetics in peripheral nerve blocks have been demonstrated in randomised clinical trials. The chosen primary outcome and anticipated effect size have major impact on the clinical relevance of results in these trials. This scoping review aims to provide an overview of frequently used outcomes and anticipated effect sizes in randomised trials on peripheral nerve block adjuncts. For our scoping review, we searched MEDLINE, Embase and CENTRAL for trials assessing effects of adjuncts for peripheral nerve blocks published in 10 major anaesthesia journals. We included randomised clinical trials assessing adjuncts for single-shot ultrasound-guided peripheral nerve blocks, regardless of the type of interventional adjunct and control group, local anaesthetic used and anatomical localization. Our primary outcome was the choice of primary outcomes and corresponding anticipated effect size used for sample size estimation. Secondary outcomes were assessor of primary outcomes, the reporting of sample size calculations and statistically significant and non-significant results related to the anticipated effect sizes. Of 11,854 screened trials, we included 59. The most frequent primary outcome was duration of analgesia (35/59 trials, 59%) with absolute and relative median (interquartile range) anticipated effect sizes for adjunct versus placebo/no adjunct: 240 min (180-318) and 30% (25-40) and for adjunct versus active comparator: 210 min (180-308) and 17% (15-28). Adequate sample size calculations were reported in 78% of trials. Statistically significant results were reported for primary outcomes in 45/59 trials (76%), of which 22% did not reach the anticipated effect size. The reported outcomes and associated anticipated effect sizes can be used in future trials on adjuncts for peripheral nerve blocks to increase methodological homogeneity.

Investigation of Appropriate Scaling of Networks and Images for Convolutional Neural Network-Based Nerve Detection in Ultrasound-Guided Nerve Blocks.

Ultrasound imaging is an essential tool in anesthesiology, particularly for ultrasound-guided peripheral nerve blocks (US-PNBs). However, challenges such as speckle noise, acoustic shadows, and variability in nerve appearance complicate the accurate localization of nerve tissues. To address this issue, this study introduces a deep convolutional neural network (DCNN), specifically Scaled-YOLOv4, and investigates an appropriate network model and input image scaling for nerve detection on ultrasound images. Utilizing two datasets, a public dataset and an original dataset, we evaluated the effects of model scale and input image size on detection performance. Our findings reveal that smaller input images and larger model scales significantly improve detection accuracy. The optimal configuration of model size and input image size not only achieved high detection accuracy but also demonstrated real-time processing capabilities.

Effectiveness of Peripheral Nerve Block in Terms of Search for a Standardized Treatment Protocol in Diabetic Foot Patients Using Anticoagulants: A Double-Center Study.

Lower-extremity amputation for a diabetic foot is mainly performed under general or central neuraxial anesthesia. Ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and patients with additional comorbidities. We evaluated bleeding due to PNB application in patients with diabetic foot receiving antiplatelet or anticoagulant therapy. Perioperative morbidity and mortality and the need for intensive care hospitalization were analyzed. This study included 105 patients with diabetic foot or debridement who underwent distal foot amputation or debridement between February and October 2020. Popliteal nerve block (17 mL of 5% bupivacaine and 3 mL of saline) and saphenous nerve block (5 mL of 2% lidocaine) were applied to the patients. Postoperative pain scores (at 4, 8, 12, and 24 hours) and complications due to PNB were evaluated. Intensive care admission and 1-month mortality were recorded. The most common diseases accompanying diabetes were hypertension and peripheral artery disease. No complications due to PNB were observed. Mean ± SD postoperative first analgesic need was determined to be 14.1 ± 4.1 hours. Except for one patient, this group was followed up without the need for postoperative intensive care. In 16 patients, bleeding occurred as leakage from the surgical area, and it was stopped with repeated pressure dressing. Mean ± SD patient satisfaction score was 8.36 ± 1.59. Perioperative mortality was not observed. Ultrasound-guided PNB can be an effective and safe anesthetic technique for diabetic patients undergoing distal foot amputation, especially those receiving antiplatelet or anticoagulant therapy and considered high risk.

Evaluation of the effectiveness of artificial intelligence for ultrasound guided peripheral nerve and plane blocks in recognizing anatomical structures

BackgroundWe aimed to assess the accuracy of artificial intelligence (AI) based real-time anatomy identification for ultrasound-guided peripheral nerve and plane block in eight regions in this prospective observational study. MethodsAfter obtaining ethics committee approval and written informed consent from 40 healthy volunteers (20 men and 20 women, between 18 and 72 years old), an ultrasound device installed with AI software (Nerveblox, SmartAlfa, Turkey) were used to scan regions of the cervical plexus, brachial plexus, pectoralis (PECS), rectus sheet, femoralis, canalis adductorius, popliteal, and ESP by three anesthesiology trainees. During scanning by a trainee, once software indicates 100 % scan success of associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 6-point scale between 0 and 5 by two expert validators. Evaluation scores of the validators for each block were compared according to demographics (gender, age, and BMI) and block type exists. ResultsThe scores were not different except ESP, femoralis, and cervical plexus regions between the experts. The mean scores of the experts for the PECS, popliteal and rectus sheath were significant between males and females (p < 0.05). In terms of BMI, significant differences in the scores were observed only in the canalis adductorius, brachial plexus, and ESP regions (p < 0.05). ConclusionsUltrasound guided AI-based anatomy identification was performed in commonly used eight block regions by the trainees where AI technology can successfully interpret the anatomical structures in real-time sonography which would be valuable in assisting anesthesiologists.

Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review

BackgroundShoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. ObjectiveThe aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. MethodsAdhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. ResultsFive studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). ConclusionsUSG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.

(016) Outpatient, Multimodal Neuromuscular Treatment Reduces Pain and Improves Functionality for Patients with Chronic Pelvic Pain and Vulvodynia

Abstract Introduction Characterized by chronic pain and/or discomfort around the opening of the vulva, Vulvodynia is known to affect up to 16% of adult women. Vulvodynia may present as constant or intermittent pain which negatively impacts patients’ personal and working lives, as well as mental health and relationships. The cause of Vulvodynia is unknown, and treatment is not widely agreed upon. Objective The purpose of this study was to test the effectiveness of a multimodal neuromuscular treatment protocol in treating the symptoms of Chronic Pelvic Pain and Vulvodynia, improving pain and function. Methods 59 patients ages 20-79 who presented to an outpatient clinic for treatment of pelvic pain and Vulvodynia symptoms. These symptoms had persisted for an average of 6 years. All patients underwent a once weekly, six-week treatment consisting of ultrasound-guided pelvic floor musculature trigger-point injections and peripheral nerve blocks. To measure the effects of this treatment, a 0-10 Visual Analogue Scale (VAS) was used to measure pelvic pain intensity, and the Functional Pelvic Pain Scale (FPPS) was used to measure function across multiple areas. These measures were taken at patients’ first visit to a clinic, and three months after treatment began. Results VAS scores improved by an average of 51%. Before treatment, the mean VAS score was 7.93 (SD=1.61) (a=0.05; CI 7.52-8.34) and the posttreatment mean VAS score was 3.9 (SD=2.19) (a=0.05; CI 3.34-4.46) (P&amp;lt;0.0001). Pelvic pain functionality improved by 23% after three months. Pretreatment FPPS scores averaged at 12.34 (SD=5.8) (a=0.05; CI 10.86-13.82), decreasing to 9.53 (SD=5.43) (a=0.05; CI 8.14-10.91) after treatment (P&amp;lt;0.0001). FPPS functions which showed the greatest improvement were Sleep, which improved by 39%, Intercourse, which improved by 28%, and Walking, which improved by 28%. Conclusions These results indicate that a six-week treatment consisting of once-weekly ultrasound-guided pelvic floor musculature trigger-point injections and peripheral nerve blocks combined with once-weekly pelvic floor physical therapy was very effective at relieving pain and improving function for patients with Vulvodynia. Disclosure No

Ultrasound Guided Combined Peripheral Nerve Blocks in a High-Risk Patient: A Case Report

The use of ultrasound in peripheral nerve blocks has become increasingly more frequent. Lower–extremity surgeries are mainly performed under general or central neuraxial anesthesia, ultrasound-guided combined peripheral nerve block (PNB) can be a good alternative anesthetic technique, especially for high-risk patients who require continuous anticoagulation treatment and present with poor cardiovascular conditions.

Effect of Adding Perineural Methylprednisolone to Peripheral Nerve Blocks Combined With Intravenous Dexamethasone for Prolonged Postdischarge Analgesia After Fast-track Total Knee Arthroplasty

Patients undergoing total knee arthroplasty (TKA) may experience moderate-to-severe subacute pain after hospital discharge that may be undermanaged. We aimed to evaluate the effect of methylprednisolone added to ultrasound-guided peripheral nerve blocks (PNBs) combined with multimodal analgesia including intravenous dexamethasone for prolonged analgesia after early discharge. We randomized 80 patients who underwent fast-track TKA into 2 groups. All patients received a periarticular injection, PNBs, and multiple doses of intravenous dexamethasone. The methylprednisolone group received 140mg methylprednisolone in PNBs, while the nonmethylprednisolone group did not. The primary outcome was the incidence of moderate-to-severe pain (Numerical Rating Scale ≥4) during the first 12 postdischarge days. The secondary outcomes included pain scores until 3 postoperative months, incidence of rebound pain, functional performances, patient satisfaction, and adverse events. No significant between-group differences were noted in the incidence of moderate-to-severe pain during the first 12 postdischarge days (nonmethylprednisolone vs. methylprednisolone groups: 70% vs. 69.2%, P=0.941). However, this incidence was significantly higher in the methylprednisolone group between 2 weeks and 1 month (P=0.015) and between 1 and 3 months (P=0.004) postoperatively. No between-group differences in the Numerical Rating Scale scores at the postdischarge time points, incidence of rebound pain, and functional performance results were noted. Adding perineural methylprednisolone to ultrasound-guided PNBs for multimodal analgesia with intravenous dexamethasone did not prolong analgesia and improved the functional ability after fast-track TKA within 12 postdischarge days. However, the incidence moderate-to-severe pain may increase between the 2-week and 3-month follow-up.

Smart needle electrical bioimpedance to provide information on needle tip relationship to target nerve prior to local anesthetic deposition in peripheral nerve block (USgPNB) procedures.

Ultrasound guided peripheral nerve block (USgPNB) refers to anaesthetic techniques to deposit local anesthetic next to nerves, permitting painful surgery without necessitating general anesthesia. Needle tip position prior to local anesthetic deposition is a key determinant of block success and safety. Nerve puncture and intra-neural injection of local anesthetic can cause permanent nerve injury. Currently ultrasound guidance is not sufficiently sensitive to reliably detect needle to nerve proximity. Feedback with bioimpedance data from the smart needle tip might provide the anesthetist with information as to the relationship between the needle tip and the target nerve prior to local anesthetic deposition. Bioimpedance using a smart needle integrated with a two-electrode impedance sensor has been developed to determine needle to nerve proximity during USgPNB. Having obtained all necessary ethical and regulatory approvals, in vivo data on brachial plexus, vagus, femoral and sciatic nerves were obtained from seven pig models using the smart needle bioimpedance system. The excision and histological analysis of above peripheral nerves and observation of the architecture and structure of nerves by means of histology allow the calculation of the ratios of connective tissue to neural tissue to determine the influence of this variable on absolute impedance. The ratio results give extra clinical data and explain the hetrogeneity of impedance data in the pig models and the hypothesis that connective tissue with intra-neural fat has higher impedance than neural tissue.

Ultrasound-guided Erector Spinae Plane Block for Postoperative Analgesia in Patients undergoing Open Nephrectomy: A Randomised Controlled Study

Introduction: Open nephrectomy poses a challenge for the anaesthesiologist due to its large subcostal incision and association with both somatic and visceral pain. While various methods exist for postoperative pain management, a single modality approach remains largely ineffective in adequate pain management. Epidural analgesia, intravenous Patient Controlled analgesia pumps, and ultrasound-guided peripheral nerve blocks are commonly used. Aim: To evaluate the efficacy of ultrasound-guided Erector Spinae Plane Block (ESPB) as a part of multimodal analgesia for postoperative pain in patients undergoing open nephrectomy, to enhance recovery after surgery. Materials and Methods: This randomised controlled study was conducted at Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India, on 48 patients undergoing open nephrectomy. They were randomly assigned to two groups: Group I received ultrasound-guided ESPB, while Group II did not receive a block before anaesthesia reversal. In the Post-Anaesthesia Care Unit (PACU), all patients were kept on intravenous Patient Controlled Analgesia (PCA) morphine, and pain was assessed using the Numeric Rating Scale (NRS) scoring. The time of first analgesic requirement and the total morphine consumption in the first 24 hours were recorded. Patient satisfaction and quality of sleep at night were evaluated using a Likert scale. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25.0. Categorical data were assessed using the Chi-square test, while the Independent t-test/Mann-Whitney test was used to determine the association between continuous data. A p-value of &lt;0.05 was considered statistically significant. Results: There were no significant differences found between the two groups in terms of age (p-value=0.999) and ASA grade (p-value=0.336). The total morphine consumption was lower in the ESP group (11 versus 17.58 mg, p-value &lt;0.0001) compared to the control group. The NRS scores during the follow-up period in the ESP group were consistently lower compared to the control group. The average number of analgesia attempts and demand for rescue analgesia were higher in the control group compared to the ESPB group. A higher proportion of ESPB patients agreed (p-value=0.002) that the overall pain management was good. More patients in the ESPB group agreed that they had slept well at night (41.7% versus 12.50%, p-value=0.023). Conclusion: Ultrasound-guided ESPB was more effective in reducing postoperative pain, facilitating enhanced recovery, and significantly reducing the requirement for opioids in the postoperative period after abdominal surgery such as open nephrectomy.

Ultrasound-Guided Peripheral Nerve Blocks for Hip Surgery: A Concise Perspective.

Ultrasound implementation for the facilitation of peripheral nerve blocks is well established. Ultrasound-guided lumbar plexus, femoral, fascia iliaca and supra-inguinal fascia iliaca compartment, pericapsular nerve group and quadratus lumborum nerve blocks have been employed for analgesia purposes in hip surgery. The combination of motor-sparing regional anesthesia strategies for optimal postoperative pain control with recovery protocols targeting to early and safe patients' mobilization constitute the current dogma of orthopedic surgery. Therefore, this editorial sets out to revisit the role of peripheral nerve blocks in postoperative pain management of hip surgery patients, under the prism of current orthopedic practice.

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries

Study objectiveTo compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED). MethodsThis prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm. ResultsA total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [−1.02(−1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [−2.166(−2.640, −1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group. ConclusionThe study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

Ultrasound-guided and Peripheral Nerve Stimulator-guided Interscalene Brachial Plexus Block in a Patient with Neurofibromatosis during the COVID-19 Pandemic

An 18-year-old female with neurofibromatosis presented for enucleation biopsy of a slow-growing soft tissue masson her right anteromedial arm during the COVID-19 pandemic. Ultrasonography was used in the mapping of thebrachial plexus and the identification of possible neurofibroma along peripheral nerves. An interscalene brachialplexus nerve block was successfully and safely achieved with ultrasonographic and peripheral nerve stimulatorguidance. Ultrasound-guided and nerve stimulator-guided peripheral nerve blocks are safe and viable anestheticmanagement options for patients with neurofibromatosis, especially in this time of the COVID-19 global pandemic.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain.

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies. In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

"Diffusion of innovations": a feasibility study on the pericapsular nerve group block in the emergency department for hip fractures.

ObjectiveHip fractures are associated with significant morbidity and mortality. Ultrasound-guided peripheral nerve blocks are a safe method to manage pain and decrease opioid usage. The pericapsular nerve group (PENG) block is a novel, potentially superior block because of its motor-sparing effects. Through training, simulation, and supervision, we aim to determine whether it is feasible to perform the PENG block in the emergency department.MethodsPhase 1 consisted of emergency physicians attending a workshop to demonstrate ultrasound proficiency, anatomical understanding, and procedural competency using a low-fidelity model. Phase 2 consisted of a prospective, observational, feasibility study of 10 patients with hip fractures. Pain scores, side effects, and opioid usage data were collected.ResultsThe median pain score at time 0 (time of block) was 9 (interquartile range [IQR], 6.5–9). The median pain score at 30 minutes was 4 (IQR, 2.0–6.8) and 3.5 (IQR, 1.0–4.8) at 4 hours. All 10 patients required narcotics prior to the initiation of the PENG block with a median dosage of 6.25 morphine milligram equivalents (MME; IQR, 4.25–7.38 MME). After the PENG block, only 30% of the patients required further narcotics with a median dosage of 0 MME (IQR, 0–0.6 MME) until operative fixation.ConclusionIn this feasibility study, PENG blocks were safely administered by trained emergency physicians under supervision. We demonstrated data suggesting a trend of pain relief and decreased opiate requirements, and further investigation is necessary to measure efficacy.

Comparison Between Ultrasound-guided Caudal Analgesia versus Peripheral Nerve Blocks for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Prospective Study.

Background and AimUltrasound (US) guided regional analgesia is a safe and effective method in providing perioperative analgesia in pediatrics with a high success rate rapid onset and fewer side effects. The aim of this study was to compare the efficacy of US-guided caudal block versus US-guided peripheral nerve blocks (femoral and sciatic nerve blocks) in providing perioperative analgesia in pediatrics undergoing unilateral lower limb surgery.MethodsChildren aged 1–12 years scheduled for unilateral lower limb surgery during the period from January 2020 to December 2021 were randomly allocated into two groups. Group C where pediatrics received US-guided caudal block, while in group P, pediatrics received US-guided femoral and sciatic nerve blocks after the induction of general anesthesia (GA). The primary aim was to compare the postoperative pain (evaluated by the COMFORT pain score) between the two groups. Secondary aims were to compare perioperative opioids used parents’ satisfaction and occurrence of side effects.ResultsPediatrics who underwent unilateral lower limb surgeries were allocated into two groups (group C and group P). There was no significant difference between patients’ baseline characteristics and the postoperative pain score at 2, 4, 16, and 20 h.’ However there was a statistical significance at 6, 8, 12, and 24 h postoperatively, frequency of analgesia as well as the total postoperative dose of opiates (nalbuphine). Time to first analgesic (nalbuphine) requirement was significantly less in group C with a mean of (9.6±2.9 h) than in group P with a mean of (15.1±3.5 h). Parents of children in group P were more satisfied than those in group C with no recorded complications for both techniques.ConclusionUS-guided lower limb peripheral nerve block is a simple and safe method to provide adequate and more prolonged analgesia compared to US-guided caudal block for lower limb surgeries in pediatrics.

Ultrasound-Guided peripheral nerve blocks for major amputation in critically ill patients with peripheral artery disease

Objective The aim of this study was to assess the safety and efficacy of major amputation under ultrasound-guided peripheral nerve blocks in critical peripheral artery disease (PAD) patients. Methods We reviewed the medical records of consecutive patients who underwent major amputation at our center between December 2012 and December 2020. The patients’ baseline demographics and comorbidities were collected. The primary outcomes were 30-day and 12-month mortality. The secondary outcomes were intraoperative events, complications and intensive care unit (ICU) admission. Results Fifteen patients classified as American Society of Anesthesiologist (ASA) III and 13 ASA IV (mean age: 76.07 ± 11.78 years) were included in the study. These patients were critically ill and had many comorbidities, such as coronary artery disease. All amputations were successfully performed under ultrasound-guided PNB without conversion to GA, but intravenous analgesia was given in 7 patients during the operation. The majority of the patients had stable hemodynamics except for 2 patients who had hypoxia, so none of the patients were transferred to the ICU postoperatively. None of the patients suffered from acute cardio-cerebral events. However, 5 patients had wound infections, and 4 of 5 patients had to receive reamputation. None of the patients died within 48 h after amputation. However, the 30-day mortality was 3.57%, and the 12-month mortality was up to 35.71%. Conclusion This study demonstrates that major amputation could be safely and effectively performed under ultrasound-guided peripheral nerve blocks for critically ill patients, and ultrasound-guided peripheral nerve blocks could be an alternative for patients at high risk of general anesthesia or spinal anesthesia.