Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2019
ReviewIn search of the Holy Grail: Poisons and extended release local anesthetics.
Regional anesthesia has been advocated as adjunct to a multimodal analgesia regimen. The limited duration of the action of available local anesthetics limits their application. Catheters, perineural or IV adjuvants, or repetition of blocks are modalities available to prolong the analgesic benefit of LRA. ⋯ New extended release local anesthetic formulations may provide time-efficient and longer duration of analgesia with a single injection. Available data on liposomal bupivacaine are promising, and more recently, it has been FDA approved for use in interscalene brachial plexus block but not for other nerve blocks at this time. Several other new formulations and compounds, such as HTX-011, Neosaxitoxin, and SABER-Bupivacaine, are also being developed and tested for their safety and analgesic potential.
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Best Pract Res Clin Anaesthesiol · Mar 2019
ReviewNovel nerve imaging and regional anesthesia, bio-impedance and the future.
Ultrasound technology has transformed the practice of regional anaesthesia. Anaesthesiologists routinely use real-time images to guide needle and local anaesthetic placement adjacent to nerves. It is widely accepted that the era of ultrasonography has improved peripheral nerve block success rates and lessened the dose of local anaesthetic required to achieve success. ⋯ Harm may still occur where the needle or local anaesthetic is misplaced, resulting in nerve injury, vascular injury or local anaesthetic systemic toxicity. Advances in both imaging and needle technology may further enhance the safety and efficacy of ultrasound-guided regional anaesthesia. This review will focus on peer review literature to characterise the clinical challenges and explore the potential solutions.
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Nerve injury is a relatively rare but devastating complication of peripheral nerve blockade (PNB). Monitoring injection pressure during PNB is one method advocated to prevent injury by detecting needle tip placement in a noncompliant position (intraneural or abutting the epineurium). Animal studies show that gross neural damage and clinical injury are associated with injection pressures exceeding 15-20 psi. ⋯ Injection pressure monitoring has been shown to prevent injection against the brachial plexus roots or femoral nerve during peripheral nerve block. Multiple methods are available to monitor injection pressure, and most of them are inexpensive and easy to use. Large-scale registry database or pragmatic trials are indicated to show that injection pressure monitoring reduces injury in a patient setting.
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Best Pract Res Clin Anaesthesiol · Mar 2019
ReviewFascia iliaca compartment blocks: Different techniques and review of the literature.
The fascia iliaca compartment block has been promoted as a valuable regional anesthesia and analgesia technique for lower limb surgery. Numerous studies have been performed, but the evidence on the true benefits of the fascia iliaca compartment block is still limited. Recent anatomical, radiological, and clinical research has demonstrated the limitations of the landmark infrainguinal technique. ⋯ With the introduction of ultrasound, a new suprainguinal approach of the fascia iliaca has been described. Research has demonstrated that this technique leads to a more reliable block of the target nerves than the infrainguinal techniques. However, more research is needed to determine the place of this technique in clinical practice.
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Best Pract Res Clin Anaesthesiol · Mar 2019
ReviewThoracic wall blocks: From paravertebral to retrolaminar to serratus to erector spinae and back again - A review of evidence.
A multitude of thoracic wall blocks have been described, including parasternal-intercostal plane, Pecs I and II, serratus anterior plane, paraspinal-intercostal plane, erector spinae plane blocks, and retrolaminar blocks. They are almost all fascial plane blocks, relying on passive spread of local anesthetic to target nerves within the plane or in adjacent tissue compartments. ⋯ They are best employed as part of multimodal analgesia with other systemic analgesics, rather than as sole anesthetic techniques. Catheters may be beneficial in situations where moderate-to-severe pain is expected for >12 h, although the optimal dosing regimen requires further investigation.