Articles: nerve-block.
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Anesthesia and analgesia · Nov 2003
Randomized Controlled Trial Clinical TrialThe use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery?
Popliteal sciatic nerve block is a commonly used technique for surgery involving the foot and ankle. However, pain can be difficult to control as the local anesthetic block wears off. Therefore, we hypothesized that extending the block by using a continuous infusion of bupivacaine (0.25%) would provide improved pain management and might facilitate the recovery process after foot or ankle surgery. In this randomized, double-blinded, placebo-controlled study, 24 consenting patients undergoing foot or ankle surgery with a standardized general anesthetic technique were studied. Before surgery, a popliteal sciatic nerve block was performed in all patients with an 18-gauge Tuohy epidural needle and a peripheral nerve stimulator. After injection of bupivacaine 0.25% 30 mL and placement of a 20-gauge catheter, patients were randomly assigned to receive either 0.9% saline (control) or bupivacaine 0.25% at a constant rate of 5 mL/h for up to 48 h after surgery. An 11-point verbal rating scale (0 = no pain to 10 = worst pain imaginable) was used to assess the severity of pain. Opioid analgesic use was recorded at specific time intervals after surgery. Follow-up evaluations were performed at 24 h, 48 h, 72 h, and 1 week after surgery to assess pain scores, as well as patient satisfaction with their pain management and quality of recovery, by using a 100-point verbal rating scale (1 = highly dissatisfied to 100 = highly satisfied). In the bupivacaine group, there was a statistically significant reduction in the maximal pain scores (>50%) and in opioid use (>60%) during the postoperative period compared with the control group. Patient satisfaction with postoperative pain management (95 +/- 3 versus 77 +/- 13) and quality of recovery (96 +/- 7 versus 83 +/- 14) was significantly improved in the bupivacaine group (versus control). In addition, 40% of the patients in the bupivacaine group (versus none in the control group) were able to be discharged home on the day of surgery (P = 0.087). In conclusion, a continuous infusion of bupivacaine 0.25% decreased postoperative pain and the need for opioid analgesic rescue medication after orthopedic surgery involving the foot and ankle, leading to improved patient satisfaction and quality of recovery. ⋯ A continuous infusion of bupivacaine 0.25% (versus saline) at the popliteal fossa by using a simple elastomeric pump is an effective method of decreasing postoperative pain, reducing the opioid analgesic requirement, and increasing patient satisfaction with pain management after orthopedic surgery involving the foot and ankle. More importantly, the use of the continuous sciatic nerve block in the popliteal fossa facilitated an earlier discharge after lower extremity surgery.
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Anesthesia and analgesia · Nov 2003
Randomized Controlled Trial Clinical TrialUltrasound guidance speeds execution and improves the quality of supraclavicular block.
In this prospective study, we assessed the quality, safety, and execution time of supraclavicular block of the brachial plexus using ultrasonic guidance and neurostimulation compared with a supraclavicular technique that used anatomical landmarks and neurostimulation. It was hypothesized that ultrasonic guidance would increase the proportion of successful blocks, decrease block execution time, and reduce the incidence of complications such as pneumothorax and neuropathy. Eighty patients were randomized into two groups of 40, Group US (supraclavicular block guided in real time by a two-dimensional ultrasonic image, with neurostimulator confirmation of correct needle position) and Group NS (supraclavicular block using the subclavian perivascular approach, also with neurostimulator confirmation). Blocks were performed using bupivacaine 0.5% and lidocaine 2% (1:1 vol) with epinephrine 1:200000 as the anesthetic mixture. The onset of motor and sensory block for the musculocutaneous, median, radial, and ulnar nerves was evaluated over a 30 min period. At 30 min 95% of patients in Group US and 85% of patients in Group NS had a partial or complete sensory block of all nerve territories (P = 0.13) and 55% of patients in Group US and 65% of patients in Group NS had a complete block of all nerve territories (P = 0.25). Surgical anesthesia without supplementation was achieved in 85% of patients in Group US and 78% of patients in Group NS (P = 0.28). No patient in Group US and 8% of patients in Group NS required general anesthesia (P = 0.12). The quality of ulnar block was significantly inferior to the quality of block in other nerve territories in Group NS, but not in Group US; the quality of ulnar block was not significantly different between Groups NS and US. The block was performed in an average of 9.8 min in Group NS and 5.0 min in Group US (P = 0.0001). No major complication occurred in either group. We conclude that ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a more complete block than supraclavicular block using anatomic landmarks and neurostimulator confirmation. ⋯ Ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a block of better quality than supraclavicular block using anatomic landmarks and neurostimulator confirmation.