Articles: nerve-block.
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There is an unsettled discussion about whether the distribution of local anesthetic is free or inhibited when performing brachial plexus blocks. This is the first study to use magnetic resonance imaging (MRI) to help answer this question. ⋯ This study demonstrated that MRI is useful in examining local anesthetic distribution in axillary blocks because it can show the correlation between MRI distribution pattern and clinical effect. The cross-sectional spread of fluid around the brachial-axillary artery was often incomplete-inhibited, and the clinical effect often inadequate.
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The antidepressant amitriptyline is commonly used orally for the treatment of chronic pain, particularly neuropathic pain, which is thought to be caused by high-frequency ectopic discharge. Among its many properties, amitriptyline is a potent Na(+) channel blocker in vitro, has local anesthetic properties in vivo, and confers additional blockade at high stimulus-discharge rates (use-dependent blockade). As with other drug modifications, adding a phenylethyl group to obtain a permanently charged quaternary ammonium derivative may improve these advantageous properties. ⋯ N-phenylethyl amitriptyline appears to have a narrow therapeutic range but is much more potent than lidocaine, providing a block duration several times longer than any clinically used local anesthetic. Further work in animal models of neuropathic pain will assess the potential use of this drug.
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Early and efficient rehabilitation is necessary for improving outcome after shoulder surgery. Pain, which is severe to very severe in this condition, is the major factor which compromises early physical therapy. Interscalene block is a well recognized and efficient technique for controlling pain after major open shoulder surgery. ⋯ However, the application of a continuous infusion of local anaesthetics through an interscalene catheter is actually the best technique available to achieve pain relief at rest and on movement after this type of surgery. This chapter emphasizes the advantages of the modified lateral approach, the use of patient-controlled interscalene analgesia and the traps and tricks of the interscalene block. Thus, this chapter demonstrates why interscalene anaesthesia and analgesia are the most appropriate techniques for shoulder surgery.
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The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. ⋯ This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewMajor surgery in the ambulatory environment: continuous catheters and home infusions.
The ability to provide continuous peripheral nerve blocks to patients safely on an outpatient basis has been a major advance in ambulatory surgery over the past several years. The first reports of patients self-administering local anaesthetic via wound and perineural catheters were published in 1998. Such infusions have now become a necessary component for the success of various ambulatory procedures. ⋯ Many of the concepts used to provide safe ambulatory infusion have been drawn from studies of patients receiving these types of therapies in a hospital setting. Few studies have actually examined these techniques is an outpatient environment. However, the advantages of these analgesic techniques over traditional oral narcotics for patients undergoing major surgery in the ambulatory environment have led to their rapid acceptance as a standard of care at many institutions.