Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Nov 2018
Anatomical Look Into OnabotulinumtoxinA Injection for Chronic Migraine Headache.
While existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. ⋯ Our study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.
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Reg Anesth Pain Med · Nov 2018
Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study.
The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space.We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. ⋯ The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA.
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Reg Anesth Pain Med · Nov 2018
Randomized Controlled Trial Comparative StudyUltrasound-Guided Infraclavicular Brachial Plexus Block: Prospective Randomized Comparison of the Lateral Sagittal and Costoclavicular Approach.
It has recently been proposed that an infraclavicular brachial plexus block (BPB) at the costoclavicular (CC) space may overcome some of the limitations of the lateral sagittal (LS) approach. In this study, we hypothesized that the CC approach will produce faster onset of sensory blockade of the 4 major terminal nerves of the brachial plexus than the LS approach. ⋯ This study was registered at the Centre for Clinical Trials of The Chinese University of Hong Kong, identifier CUHK_CCT00389.
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Reg Anesth Pain Med · Nov 2018
Is a Retrolaminar Approach to the Thoracic Paravertebral Space Possible?: A Human Cadaveric Study.
The retrolaminar block (RB) is used for truncal analgesia, but its mechanism of neural blockade remains obscure. We sought to learn the pattern of local anesthetic spread after thoracic RB using cadaveric models. ⋯ Injectate spread to the paravertebral space, epidural space, intercostal space, and intervertebral foramina is possible in the RB but is quite variable. In comparison to the thoracic paravertebral block, injectate spread within the paravertebral space is more limited.
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Reg Anesth Pain Med · Nov 2018
ReviewEsmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care.
β-Adrenergic blockade is an important mechanism for reducing morbidity and mortality in patients with hypertension and heart failure. Esmolol has been used widely for its chronotropic and antihypertensive effects. However, there has been recent inquiry regarding perioperative esmolol use and nociceptive modulation. ⋯ Esmolol, to date, has not shown any direct analgesic or anesthetic properties; however, recent studies suggest that esmolol may have antinociceptive and postoperative opioid-sparing effects. In this Daring Discourse narrative, we describe the role of esmolol in current perioperative β-blockade guidelines (related to noncardiac surgery), briefly describe studies supporting the antinociceptive effects of esmolol, propose mechanisms for esmolol antinociception, and forecast potential routine esmolol use intraoperatively (as part of a multimodal total intravenous anesthetic) and its effects on opioid sparing. The reading audience of regional anesthesiologists and acute pain medicine physicians is uniquely positioned to take a lead role in promulgating this care advance amid (i) the unwanted effects of the opioid epidemic and (ii) the uncertain notion of whether routine general anesthesia care (with fentanyl) may indirectly be contributing to the epidemic.