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PubMed2006

Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: a randomized clinical trial.

BACKGROUND: Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. METHODS: Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1-4 and 7 to determine NRS scores (scale 0-10). RESULTS: Data from 233 participants were analyzed. On days 1-2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1-4, group II was the only factor predicting lower pain scores (odds ratios, 0.3-0.5; P = 0.001-0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1-7 (odds ratios, 3.3-5.2; P < 0.001). CONCLUSIONS: Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.

Adolescent↗

PubMed1995

Computerized axial tomography to define the distribution of solution after stellate ganglion nerve block.

STUDY OBJECTIVE: To define the spread of local anesthetic after C6 stellate ganglion nerve block using computerized axial tomography (CAT). DESIGN: Prospective, open descriptive study. SETTING: Outpatient pain consult center. PATIENTS: 10 ASA status I patients undergoing stellate ganglion nerve blocks for sympathetically maintained pain. INTERVENTIONS: Radiocontrast and local anesthetic was given in 5 ml increments to 20 ml total volume for C6 stellate ganglion nerve blocks in eight patients and C7 in two patients. MEASUREMENTS AND MAIN RESULTS: CAT scanning was performed at baseline and after 5, 10, 15, and 20 ml of injectate was administered. Cervical level and pattern of injectate spread was recorded after each increment. Neck pressure above C6 did not promote caudal spread. One half of the injections were beneath prevertebral fascia. Injections on top of the fascia spread more diffusely around C6. All injections in high volume reached the medial aspect of T1 around the head, not neck, of the first rib. CONCLUSIONS: Solutions injected for C6 stellate ganglion nerve block concentrate medial to the stellate ganglion at T1. Thus, they must produce upper extremity sympathectomy by a mechanism other than contact with the ganglion.

Adult↗

PubMed2004

The addition of clonidine to bupivacaine in combined femoral-sciatic nerve block for anterior cruciate ligament reconstruction.

Clonidine has been shown to prolong sensory analgesia when given as an adjunct to peripheral nerve blocks but has not been evaluated when given in conjunction with a femoral-sciatic nerve block. The purpose of this investigation was to determine whether the addition of clonidine to a femoral-sciatic nerve block would prolong the duration of sensory analgesia in groups of patients undergoing anterior cruciate ligament (ACL) reconstruction. This prospective, randomized, double-blind investigation was performed on 64 subjects undergoing ACL reconstruction. Patients were assigned randomly to receive a femoral-sciatic nerve block using 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine (control group) or 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 1 microg/kg of clonidine (experimental group). Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia, and patient satisfaction. No significant differences were noted between groups for pain intensity scores, duration of sensory analgesia, postoperative analgesic requirements, or overall patient satisfaction. Both groups reported minimal amounts of postoperative pain and high analgesic satisfaction scores. Based on our results, we do not recommend the addition of clonidine to a femoral-sciatic nerve block when given to facilitate postoperative analgesia in patients undergoing ACL reconstruction.

Adult↗

PubMed1998

Anesthetic efficacy of the intraosseous injection of 0.9 mL of 2% lidocaine (1:100,000 epinephrine) to augment an inferior alveolar nerve block.

OBJECTIVE: The purpose of this study was to determine the anesthetic efficacy of an intraosseous injection of 0.9 mL of 2% lidocaine with 1:100,000 epinephrine to augment an inferior alveolar nerve block in mandibular posterior teeth. STUDY DESIGN: With the use of a repeated-measures design, each of 38 subjects randomly received one or the other of 2 combinations of injections at 2 separate appointments. The combinations were inferior alveolar nerve block + intraosseous injection (on the distal of the second premolar) through use of 0.9 mL of 2% lidocaine with 1:100,000 epinephrine and inferior alveolar nerve block + mock intraosseous injection. The first molar, second premolar, and second molar were blindly tested with an Analytic Technology pulp tester at 2-minute cycles for 120 minutes postinjection. Anesthesia was considered successful when 2 consecutive 80 readings were obtained. RESULTS: One hundred percent of the subjects had lip numbness with the inferior alveolar nerve block + intraosseous injection combination technique. The respective anesthetic success rates for the inferior alveolar nerve block + mock intraosseous injection combination and the inferior alveolar nerve block + intraosseous injection combination were 60% and 100% for the second premolar, 71% and 95% for the first molar, and 74% and 87% for the second molar. The differences were significant (P < .05) for the second premolar through 50 minutes and for the first molar through 20 minutes. There were no significant (P > .05) differences for the second molar. Sixty-eight percent of the subjects had a subjective increase in heart rate with the intraosseous injection. CONCLUSIONS: The results of this study indicate that the supplemental intraosseous injection of 0.9 mL of 2% lidocaine with 1:100,000 epinephrine, given distal to the second premolar, significantly increased the success of pulpal anesthesia in the second premolar (for 50 minutes) and first molar (for 20 minutes) in comparison with the inferior alveolar nerve block alone. The intraosseous injection did not statistically increase success in the second molar.

Adolescent↗

PubMed2006

C-arm-guided pudendal nerve block: a new technique.

Pudendal nerve block (PNB) is an effective diagnostic and/or treatment method for perineal pain. Various approach techniques, such as transperineal, transvaginal, computerised tomography (CT)- or sono-guided approach, have been suggested for this block. However, they have some limitations, such as high cost, difficulty to perform in practice, inaccurate and unreliable results and inconvenience. To overcome these limitations, we first tried C-arm-guided approach for accomplishing PNB in the prone position. Under the optimal ischial spine view of C-arm fluoroscopy, the block needle was placed on the tip of the ischial spine. Then a mixed solution for the block was administered. All of the 25 patients enrolled in this study were blocked successfully using this method. No side-effects or complications were observed in relation to the block. We concluded that the C-arm-guided approach for PNB is an effective alternative to the existing techniques, which can overcome their limitations.

Adult↗

PubMed1991

[Midazolam as a premedicant for trigeminal nerve blocks].

Although patients with trigeminal neuralgia can be treated satisfactorily with nerve blocks, the block procedure is sometimes very painful and uncomfortable for them. To investigate the efficacy and adverse effects of midazolam as a premedicant for trigeminal nerve blocks, 19 patients were randomly assigned to receive either midazolam (0.05 mg.kg-1, n = 6), midazolam (0.1 mg.kg-1, n = 7), or saline/placebo (n = 6) before the block. The patients given midazolam (0.1 mg.kg-1) had a significantly lower incidence of recalling the block procedure and had complained of less discomfort when interviewed the following day. No serious adverse effects were observed in any patient given midazolam. Midazolam can be used safely as an effective premedicant for potentially uncomfortable procedures such as trigeminal nerve blocks.

Aged↗

PubMed1998

Common peroneal nerve block for sciatica.

The effectiveness of common peroneal nerve block for lumbar disc herniation was evaluated in a double blind study. Common peroneal nerve block was performed near the fibular head in nine patients using 2% lidocaine and in 10 patients using saline. The average pain scale score decreased from 3.1 to 0.6 in the lidocaine group, whereas it decreased from 3.0 to 2.6 in the placebo group. The average result in the straight leg raising test increased from 61 degrees to 84 degrees in the lidocaine group, but from 44 degrees to 50 degrees in the placebo group. Lower leg pain lessened more in the lidocaine group than in the placebo group. The finding that lower leg pain disappeared or decreased with a lidocaine block at a site far distal to the lumbar lesion suggests that impulses that are transmitted distal to the lesion may be important for the generation of sciatic radicular pain.

Adult↗

PubMed2003

Dorsal penile nerve block.

BACKGROUND: The dorsal penile nerve block (DPNB) is a common form of regional anaesthesia for circumcisions in children. The safety of this block has been questioned following several case reports of potentially serious complications. METHODS: We performed a retrospective review of all the incidents related to the conduct of this block in our institution over a period of 53 months. RESULTS: A total of 3909 circumcisions were performed under DPNB and nine incidents were recorded. This included two cases of bleeding from the prepuce, two urethral injuries, three haematomas and two drug errors. Two cases required further surgical intervention but all of the patients recovered with no apparent long-term sequelae. CONCLUSIONS: We feel that the DPNB is a safe technique for circumcisions in infants and children.

Child↗

PubMedDate not supplied

Is there any need for expanding the perineural space before catheter placement in continuous femoral nerve blocks?

BACKGROUND AND OBJECTIVE: There is debate regarding the benefit of perineural space expansion before catheter placement in continuous femoral nerve block. This question is addressed in this prospective, comparative, and randomized study. METHODS: Sixty patients scheduled for total knee replacement were randomly assigned to receive continuous femoral nerve block with or without perineural space expansion using 10 mL dextrose 5% in water (D5W) flush before stimulation-guided catheter placement. Femoral block was initiated with a 5-mL bolus followed by an infusion of 5 mL/h ropivacaine 0.2% during the 2-hour surgery. The number of attempts before successful placement of the stimulating catheter and the resistance during its insertion were assessed. Patients also received obturator nerve blocks by using ropivacaine 0.75% (10 mL) and sciatic nerve blocks (20 mL). The number of boluses of ropivacaine 0.2% needed to achieve zero VAS scoring was recorded in the postanesthesia care unit during the 2-hour stay. Images of the contrast spread were also studied. RESULTS: There were 30 patients in each group. The number of successful catheter placements at the first attempt was higher with expansion than without (22 vs. 8, P = .007). The resistance felt during insertion was lower with than without expansion (P = .01). More boluses of ropivacaine were required postoperatively without expansion (P = .03). No difference between groups was found regarding the images of the contrast spread. CONCLUSION: Expansion of the perineural space with D5W is useful for catheter placement in continuous femoral nerve block.

Adult↗

PubMed2004

Comparison of regional nerve block to epidural anaesthesia in day care arthroscopic surgery of the knee.

Day care minimally invasive surgery demands minimal complications with anaesthesia. Nerve blocks are increasingly being employed for surgical procedures on the lower limb, and we attempted to evaluate their benefits and drawbacks in a prospective randomised study in patients undergoing knee arthroscopy. We compared the effectiveness, onset time, duration of analgesia, patient acceptance, failure rate and post-operative comfort of epidural anaesthesia (with 20 ml of 2% lidocaine with adrenaline 1 in 200000) and peripheral nerve blocks (combined 3-in-1 and sciatic nerve block, with 50 ml of 1% lignocaine with adrenaline 1 in 200000, using nerve stimulator). Forty nine cases were randomised to receive either single shot epidural anaesthesia (Group-I, n = 23) or combined 3-in-1 and sciatic nerve block (Group-II, n = 26). The anaesthesia procedure and analgesia onset time was longer in Group-II (p < 0.001), with skin incision being significantly delayed as compared to group-I (45.2+/-6.2min vs 30.0+/-5.4 min respectively) (p < 0.001). Haemodynamic changes were comparable in both groups during the study period. All patients had complete analgesia at skin incision in group-I as compared to 89.1% in group-II (p < 0.05). However 52.2% of patients in group-I required rescue analgesia postoperatively, as compared to only 18.7% in group-II (p < 0.05). We concluded that even though combined 3-in-1 and sciatic nerve block technique has longer anaesthesia induction time, the lesser need for postoperative rescue analgesia, and lesser potential complications like inadvertent spinal puncture, retention of urine and late onset of back pain, make this an attractive option for day care arthroscopy. The use of a nerve stimulator ensures accuracy, patient counselling allows good cooperation, and advance planning can include potential skin incision delays.

Adolescent↗

PubMed1991

[Management of pain after thoracotomy: experience of intercostal nerve block with alcohol during operation].

Post-thoracotomy wound pain in 11 patients who underwent thoracic operation was controlled by intercostal nerve block with alcohol and thoracic epidural anesthesia. The intercostal nerve block was performed just before the closure of the thoracotomy wound. Epidural anesthesia was employed from the 1st to 5th post operative day. This method alleviated post-thoracotomy pain and obviated postoperative pulmonary complication in all patients in early post operative periods. In late post operative periods after discharge, intercostal nerve block could maintain excellent analgesia in 9 of 11 patients, only 2 patients required analgesic drugs or re-block of the intercostal nerve. Thus, intercostal nerve block with alcohol is an effective and simple option to control recalcitrant post-thoracotomy wound pain in thoracic surgery.

Adult↗

PubMed2001

Sensitivity of sensory axons to lidocaine nerve block in rats.

The aim of the present study was to test the sensitivity of different classes of sensory axons to lidocaine 2 and 4% nerve block. The basic approach was to examine changes in compound action potential (CAP) of A and C axons of the rat sural nerve induced by 2 or 4% lidocaine nerve block in vitro. CAP in control sural nerves (n = 6 for each experimental group) before nerve block was induced, consisted of the early component (A axons: 0.3 +/- 0.02 ms) and the late component (C axons: 12.2 +/- 1.14 ms) with peak voltage amplitudes 4.4 +/- 1.4 mV and 0.04 +/- 0.02 mV, respectively. Lidocaine 2% nerve block completely abolished the amplitude of CAP of C axons and depressed the amplitude of CAP of A axons to about 20 % of control level. Doubled concentration of lidocaine significantly decreased time taken to develop maximal depression of CAP and significantly increased excitation threshold of sensory A axons, but not of sensory C axons. However, 4% lidocaine did not affect the maximal depression of CAP of sensory A axons. These results support the view, that C axons are more sensitive to lidocaine nerve block than A axons. In addition, our results suggest a population of sensory A axons which is non-sensitive to 2% and 4% lidocaine.

Action Potentials↗

PubMedDate not supplied

A paravenous approach for the saphenous nerve block.

BACKGROUND AND OBJECTIVES: This study assesses a paravenous approach for saphenous nerve block at approximately the level of the tibial tuberosity, and compares it with the conventional technique of blind subcutaneous infiltration between the tibial tuberosity and the gastrocnemius muscle. METHODS: In dissections of 5 cadavers, the saphenous nerve was found very close to the saphenous vein bilaterally. Subsequently, in 20 volunteers, a bilateral saphenous nerve block was performed with 5 mL mepivacaine on each side. Randomly assigned, the block was performed by blind subcutaneous injection using a 23-gauge needle of 2.5 cm on one side and by a paravenous subcutaneous approach on the other. RESULTS: The paravenous approach produced a saphenous nerve block in all 20 volunteers whereas the blind subcutaneous approach was successful in only 6 (33%) (P <.05). Seven volunteers had a painless minor hematoma at the paravenous site and 2 had a hematoma at the classical site. CONCLUSION: The saphenous nerve can be blocked effectively by a paravenous approach using only 5 mL of local anesthetic solution. This approach is advantageous because of its easily identifiable landmark.

Adult↗

PubMed2001

Incidence of pneumothorax from intercostal nerve block for analgesia in rib fractures.

BACKGROUND: The incidence of pneumothorax (PTX) after individual intercostal nerve block (INB) for postoperative pain reportedly varies from 0.073% to 19%.1-3 This study investigated the incidence of PTX after INB for rib fractures. METHODS: We conducted a retrospective chart review of patients admitted between January 1996 and December 1999 with rib fractures who received INB. RESULTS: One hundred sixty-one patients received 249 intercostal nerve block procedures (INBPs). An INBP is one session where a set of intercostal nerves are blocked. A total of 1,020 individual intercostal nerves were blocked. There were 14 pneumothoraces. The overall incidence of PTX per patient was 8.7%, with an incidence of PTX per INBP of 5.6%. The incidence of PTX was 1.4% for each individual intercostal nerve blocked. CONCLUSION: The incidence of PTX per individual intercostal nerve blocked is low. INB is an effective form of analgesia, and for most patients with rib fractures one INBP is sufficient to allow adequate respiratory exercises and discharge from the hospital.

Analgesia↗

PubMed2005

Clonidine administered as adjuvant for bupivacaine in ilioinguinal-iliohypogastric nerve block does not prolong postoperative analgesia.

BACKGROUND: Coadministration of clonidine with local anesthetics is associated with improvement of the quality of peripheral nerve block and significant prolongation of postoperative analgesia. Better analgesia has been reported with clonidine in ilioinguinal nerve block compared with caudal use. The object of this study was to determine whether adding of 1 microg.kg(-1) clonidine to bupivacaine 0.25% in ilioinguinal-iliohypogastric nerve block prolongs postoperative analgesia in children. METHODS: Ninety-eight children ASA I-II aged between 1 and 12 years, scheduled for elective outpatient herniorrhaphy or orchidopexy were randomly allocated to receive an ilioinguinal-iliohypogastric nerve block either with 0.3 ml.kg(-1) bupivacaine 0.25% plus 1 microg.kg(-1) clonidine or only bupivacaine. Postoperative analgesic needs, time to the first analgesic supplementation and sedation score were assessed in hospital for 6 h postoperatively and at home by telephone call. RESULTS: Demographic data were similar in both groups. There was no statistical difference in the rate of rescue analgesia between the two groups during the first six postoperative hours (20.4% group clonidine vs 30.6% group no clonidine) (P = 0.17). A slight decrease in systolic blood pressure during surgery was reported in the clonidine group. There was no difference in the scores of sedation between the two groups. At home, 10 patients in the clonidine group and nine patients in the nonclonidine group received analgesic medication. There was no difference between the two groups regarding the number of patients receiving analgesic rescue during the first 24 h (log rank = 0.39). Parental satisfaction was high in both groups. CONCLUSIONS: Our study failed to demonstrate any advantage in addition of 1 microg.kg(-1) clonidine to 0.25% bupivacaine for ilioinguinal-iliohypogastric nerve block compared with bupivacaine 0.25% alone.

Adjuvants, Anesthesia↗

PubMed2003

On the mechanism by which epinephrine potentiates lidocaine's peripheral nerve block.

BACKGROUND: Adding epinephrine to lidocaine solutions for peripheral nerve block potentiates and prolongs the action, but by incompletely understood mechanisms. In an effort to discriminate the pharmacokinetic from the pharmacodynamic effects of epinephrine, the authors measured the lidocaine content of peripheral nerve over the course of block produced by 0.5% lidocaine, with and without epinephrine, and correlated it with the degree of analgesia. METHODS: Percutaneous sciatic nerve blocks were performed in 18 groups of rats (10 in each) with 0.1 ml of either 0.5% lidocaine or 0.5% lidocaine with epinephrine (1:100,000). Over the full course of nerve block, the authors regularly measured analgesia to toe pinch and then rapidly removed nerves to assay intraneural lidocaine content at 2-120 min after injection. RESULTS: The kinetics of lidocaine's clearance from nerve was composed of a fast-decaying transient superimposed on a very slowly decaying component. The effect of epinephrine on the intraneural lidocaine content was to increase the amount of lidocaine in the slow-decaying component by threefold to fourfold, although the total neural content was not altered by epinephrine for the first 10 min after injection. Epinephrine prolonged blockade by almost fourfold and enhanced the intensity of peak analgesia, as well as the fraction of rats with complete block, almost throughout the 2-120-min period of behavioral observation. CONCLUSIONS: Adding epinephrine to lidocaine solutions increases the intensity and duration of sciatic nerve block in the rat. The early increase in intensity is not matched with an increase in intraneural lidocaine content at these early times, although the prolonged duration of block by epinephrine appears to correspond to an enlarged lidocaine content in nerve at later times, as if a very slowly emptying "effector compartment" received a larger share of the dose. The increase in early analgesia without increased lidocaine content may be explained by a pharmacodynamic action of epinephrine that transiently enhances lidocaine's potency, but also by a pharmacokinetic effect that alters the distribution of the same net content of lidocaine within the nerve.

Algorithms↗

PubMedDate not supplied

Femoral nerve block. Single injection versus continuous infusion for total knee arthroplasty.

BACKGROUND AND OBJECTIVES: This study was conducted to ascertain whether there is any advantage to the continuous-infusion femoral 3-in-1 nerve block over the single-injection femoral nerve block for postoperative analgesia after total knee arthroplasty. METHODS: A double-blind, randomized, controlled study was made of 33 patients undergoing total knee arthroplasty, who were randomized into three groups. Group 1 received a single-injection femoral 3-in-1 nerve block with 20 mL 0.5% bupivacaine with 1:200,000 epinephrine. Group 2 had a catheter placed in the femoral nerve sheath, through which a continuous femoral 3-in-1 nerve block was established. Group 3 patients served as controls. All blocks were performed and assessed prior to induction of standardized general anesthesia. All patients received morphine via patient-controlled analgesia. Pain was recorded on a 100-mm visual analog scale at rest and with motion of the knee. Opioid consumption and side effects were recorded; P = .05 was considered statistically significant. RESULTS: In the recovery room, pain scores with motion were lower in the single-injection and continuous-infusion groups (P < .05). There were no significant differences between any of the groups regarding pain scores or morphine requirements beyond the recovery room. The incidence of nausea was higher in the control group. There were no differences between the groups with respect to overall patient satisfaction. CONCLUSIONS: We were unable to confirm improvements in analgesia provided by continuous-infusion femoral 3-in-1 nerve block for total knee arthroplasty except in the recovery room.

Aged↗

PubMed1983

Evaluation of acute knee injuries with sciatic/femoral nerve blocks.

A preliminary study of the applicability of sciatic and femoral regional nerve blocks in the evaluation of acute knee injuries was conducted. During the period from January 1980 to March 1981, 12 patients with acute knee injuries in whom clinical examination under local anesthesia was considered totally unreliable secondary to patient uncooperation or severe pain were examined at Grady Memorial Hospital. Each of these patients received regional anesthesia by sciatic/femoral nerve block. All patients obtained satisfactory relaxation and analgesia for complete evaluation, and 92% obtained total analgesia for the knee. A full range of motion was present in each patient after the block. No complications were encountered. A satisfactory block was obtained in one attempt in 96% of the patients. (One patient had a failed femoral nerve block, but a repeated block was successful).

Acute Disease↗