Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Mar 2010
ReviewEvidence-based medicine: ultrasound guidance for truncal blocks.
We performed a systematic search of the medical literature and reviewed the evidence examining success rates and incidence of complications of ultrasound (US) guidance relative to traditional techniques for the following blocks: paravertebral, intercostal, transversus abdominis plane, rectus sheath, and ilioinguinal/iliohypogastric. We included studies of sufficient methodologic quality for review and excluded poor-quality studies. ⋯ Although relatively few studies have compared US guidance with established techniques, the available evidence suggests that the use of US guidance is a safe and effective means to facilitate correct needle placement and adequate spread of local anesthetic for truncal blocks. Further studies are needed to directly compare US guidance to traditional techniques and to clarify potential benefits and limitations of US guidance for truncal blocks.
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Reg Anesth Pain Med · Mar 2010
ReviewEvidence basis for ultrasound-guided block characteristics: onset, quality, and duration.
This systematic review summarizes existing evidence for superior onset, quality, and duration of block for ultrasound (US) guidance versus other techniques for nerve localization. ⋯ There is level 1b evidence to make a grade A recommendation that US guidance provides a modest improvement in block onset and quality of peripheral nerve blocks. Ultrasound is rarely inferior to other techniques.
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Reg Anesth Pain Med · Mar 2010
ReviewUltrasound-guided regional anesthesia and patient safety: An evidence-based analysis.
The role of ultrasound-guided regional anesthesia (UGRA) in reducing the frequency of regional anesthetic-related complications is difficult to ascertain from analyzing the limited literature on the topic. This evidence-based review critically evaluates the contributions of UGRA to improved patient safety, particularly as compared with standard nerve localization tools. Randomized controlled trials that compared UGRA with another form of neural localization and case series of more than 500 patients were used to compare safety parameters. ⋯ Statistical proof for meaningful reduction in the frequency of extremely rare complications, such as permanent peripheral nerve injury, is likely unattainable. Although there is evidence for UGRA reducing the occurrence of vascular puncture and the frequency of hemidiaphragmatic paresis, as yet there is at best inconclusive scientific proof that these surrogate outcomes are linked to actual reduction of their associated complications, such as local anesthetic systemic toxicity or predictable diaphragmatic impairment in at-risk individuals. This evidence-based review thus strives to summarize both the power and the limitations of UGRA as a tool for improving patient safety.
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Although new drugs and techniques may improve outcomes when unintended high blood levels of local anesthetics occur, the primary focus of daily practice should remain the prevention of such events. Although adoption of no single "safety step" will reliably prevent systemic toxicity, the combination of several procedures seems to have reduced the frequency of systemic toxicity since 1981. These include the use of minimum effective doses, careful aspiration, and incremental injection, coupled with the use of intravascular markers when large doses are used. ⋯ Fentanyl has also been confirmed to produce sedation in pregnant women when used as an alternative. The use of ultrasound observation of needle placement and injection may be useful, but has also been reported as not completely reliable. Constant vigilance and suspicion are still needed along with a combination of as many of these safety steps as practical.
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Reg Anesth Pain Med · Mar 2010
ReviewThe ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: Executive summary.
The American Society of Regional Anesthesia and Pain Medicine charged an expert panel to examine the evidence basis for ultrasound guidance as a nerve localization tool in the clinical practices of regional anesthesia and interventional pain medicine. ⋯ Ultrasound guidance improves block characteristics (particularly performance time and surrogate measures of success) that are often block specific and that may impart an efficiency advantage depending on individual practitioner circumstances. Evidence for UGRA impacting patient safety is currently limited to the demonstration of improvements in the frequency of surrogate events for serious complications.